s 



HOMEOPATHIC MEDICAL PRACTICE: 



SYSTEMATIC TREATISE 



DISEASES OF THE BRAIN AND EYE; 



FOR THE USE OF 



GENERAL PRACTITIONERS AND STUDENTS. 









By C. P. HART, M.D. 



FORMERLY SURGEON-IN-CHARGE OF THE SURGICAL WARDS, CHIEF SURGEON TO THE EYE 

DEPARTMENT, AND PRESIDENT OF THE BOARD OF MEDICAL EXAMINERS OF BROWN 

GENERAL HOSPITAL, LOUISVILLE, KY.J ASSISTANT EDITOR OF THE 

AMERICAN HOMOEOPATHIC OBSERVER J AUTHOR OF 

REPERTORY TO NEW REMEDIES, 

ETC., ETC. 



0, 

WITH NUMEROUS TABLES AND ILLUSTRATIONS. 






DETROIT: 

PUBLISHED BY EDWTN ALBERT LODGE, 

AMERICAN OBSERVER OFFICE. 

1878. 

ft 




Itftf 



ut* 



Entered according to Act of Congress, in the year 1877, 

By EDWIN ALBERT LODGE, 

In the Office of the Librarian of Congress, at Washington, D. C. 



ALL RIGHT RESERVED. 



Wm. A. Scripps, Printer, 

Arcade Building, 46 Larned St. West, 

Detroit, Mich. 



PREFACE. 



The present work, consisting of brief treatises on Diseases 
of the Brain and Eye, was originally designed to form the 
initial portion of a more general work on the Homoeopathic 
Practice of Medicine. But as the Author's time is now so fully 
occupied by professional duties as to prevent its speedy com- 
pletion, and as the parts are complete in themselves, and will 
make a convenient Manual on Diseases of the Brain and Eye, 
the publisher has decided to issue them as a distinct work. 
The portion relating to Ophthalmology having been published 
separately, the following remarks, taken from the Preface to 
that volume, will be equally applicable to this : 

Unfortunately, the science of which we treat is still regarded 
by many as too abstruse, and the practice of it too difficult, 
for the general profession, and hence it has been relegated, 
for the most part, to a comparatively small number of prac- 
titioners. We say unfortunately, because the vast majority of 
ophthalmic diseases are still treated, and of necessity always 
will be treated, by the ordinary medical attendant. The 
important question, then, is, not whether diseases of the eye 



4 PREFACE. 

should be turned over to the specialist for more scientific 
investigation and treatment — the propriety of which, in many- 
cases, no one who has any regard for the welfare of the patient 
will deny — but whether the general practitioner, who, nine 
times out of ten, is expected to treat these cases, shall be 
properly qualified to discharge a duty which, whether qualified 
or not, he is required to perform. Besides, even if it were 
possible for the majority of such cases to be referred to experts, 
the general practitioner would still need to be as fully informed 
on this as on other branches of medical learning, in order to 
enable him to give proper and timely advice to his patients, 
and to secure to himself the advantages, too numerous to 
mention, resulting only from a well-rounded medical education. 
Let us not be misunderstood. We are not calling in 
question the propriety of referring all complicated and difficult 
cases to specialists, but, as nine-tenths of all diseases of the 
eye are either inflammatory or functional, and as only a small 
proportion of eye difficulties, except such as require manual 
dexterity in operating, will be sent to ripe specialists — of which 
there indeed but very few— we are simply emphasizing the 
need of greater competency on the part of those who are daily 
called upon to diagnose and treat this important class of cases. 
And we opine that the chief reason the general profession is, 
as a body, so lamentably ignorant of Ophthalmology, is not in 
consequence of the abstruseness of the science, for this is no 
greater than that of any other department of medicine and 
surgery ; more especially since the discovery of the ophthal- 
moscope — the use of which has greatly simplified the subject, 



PREFACE. 5 

and rendered many parts of it much more definite and easy of 
comprehension. But we are of the opinion that the reason of 
this acknowledged incompetency lies chiefly in the paucity of 
suitable Manuals. Not that the profession is wholly without 
valuable aids of this character, but that those already published 
are, for the most part, too concise to serve as guide-books to 
the student and general practitioner, or else savor too much of 
prolixity, in consequence of the introduction of unnecessary 
details, or of matter which belongs rather to the province of 
strictly theoretical treatises. 

Whether this volume will meet the requirements above 
suggested, is not for the author to affirm. He can, however, 
truly say, that he has labored conscientiously and assiduously 
to bring it up to the standard of what he conceives to be 
requisite in a text-book of this character ; and he will feel 
amply compensated for his labors if the work shall be found 
free from any serious defects, and, at the same time, not 
wanting a reasonable degree of the only merit within the scope 
of his design, namely, that of furnishing a clear and concise 
description of ophthalmic diseases and their appropriate treat- 
ment, together with a correct and intelligible account of the 
facts, principles and discoveries furnished by the ablest of the 
American, English and German authorities. 

We have not deemed it necessary, nor even desirable, to 
cite the authority for every important statement made in the 
text. To have done so would have greatly encumbered our 
pages, and increased the size and expense of the work. We 
have, however, in most cases, given due credit for any fact or 



6 PREFACE. 

discovery the authorship of which it is important the reader 
should know ; and would refer those who desire to con- 
sult any of the original sources of information to the admirable 
treatise of Stellwag, whose bibliography of every department 
of the literature of Ophthalmology, is sufficiently ample to 
satisfy the most exacting. 

C. P. HART. 
Wyoming, Ohio, October, 1877. 



ERRATA. 



Owing chiefly to the fact that some of the proof-sheets failed to 
reach the Author in time for revision, a number or typographical 
errors remain uncorrected. Fortunately, most of them are of such a 
character as to be readily understood by the reader, and will not, 
therefore, need to be pointed out. In order, however, to avoid any 
ambiguity, the reader will please insert, the pronoun their between 
"require" and "separate," on page 102, fifth line ; omit the period 
after the word characteristic, on page 254, second paragraph; and 
substitute edgeiox "eye" in note on page 122 ; epichondral for " epis- 
cleral" on page 136, twenty-first line; it for them in the tenth and 
twelfth lines on page 188; T for " Tn" in parenthesis on page 213 ; 
and Aurum for " Arum " on page 254. 



PRACTICE OF MEDICINE. 9 

GENERAL OBSERVATIONS. 

Although this department, as its title indicates, is intended to be 
devoted strictly to the practice of medicine, yet, owing to the erro- 
neous notions still prevalent concerning the system of practice 
herein inculcated, its principles are often misunderstood, perverted 
and misapplied. It will, therefore, not only not be out of place, so 
far as may be consistent with our general plan, to endeavor at the 
outset to correct such erroneous views, by a few preliminary obser- 
vations on the true principles of our system ; but we may reasonably 
hope, by so doing, to make their practical application by the inex- 
perienced more intelligible and easy, as well as to prevent, to some 
degree, those perversions of them which arise altogether from igno- 
rance. Still, as Hahnemann himself observes, (Organon, §i,) "the 
first and sole&vXy of the physician is, to restore health to the sick," and 
not to spend his time in constructing and explaining, much less in 
contending about mere theories, whether true or false. 

In pursuance of this plan, we shall first lay down a few of the 
more important definitions and homoeopathic aphorisms, after 
which we shall treat briefly of symptoms, both pathogenetic and 
morbid,* and then of the homoeopathic medicines, their doses, du- 
ration of action, and repetition. 

DEFINITIONS AND APHORISMS. 

Disease is a departure from health \ and is either local, as affecting 
only a part of the animal sytem or functions, or constitutional^ as 
embracing, to a greater or less extent, the whole system. 

Diseases are either acute or chronic, the former term being applied 
to such derangements of the health as are speedily overcome, and 
produce no permanent organic changes ; and the latter to those 
diseases which are either slow in their development and progress, or 
which, from wrong treatment or otherwise, are extended far beyond 
the natural term of their duration. 

They are also divided into primary, and secondary or consecutive, 
the former term being applied to the original disease, or first series 

* Strictly speaking, all symptoms are morbid, since they are the result of 
diseased action ; but we shall use the term in its ordinary sense, to denote 
only those symptoms which belong to natural diseases, in contradistinction to 
those which are artificially excited, namely, the pathogenetic, or medicinal. 
2 



10 HOMOEOPATHIC 

of derangements ; and the latter to the subsequent morbid phenom- 
ena, particularly when they grow out of, or are in any way dependent 
upon, or referable to, the primary disease. 

The causes of disease may be either external or internal, mechan- 
ical, chemical, pathogenetic, or toxical. 

Among the most prolific internal causes of disease, is a depraved 
state of the blood, or taint of the system, affecting to a greater or less 
extent nearly the whole human family — the resultant of former dis- 
eases on the human system, which, variously modified, have come 
down to us from our ancestors — and called by Hahnemann, psora. 
Whatever opinion we may entertain concerning Hahnemann's theory 
on this subject, or however unfortunate he may have been — if, in- 
deed, he was unfortunate — in the selection of a term by which to 
designate this peculiar condition, the fact itself cannot be ignored, 
even by those who attempt to throw ridicule upon it. The condition 
does exist, and not only acts as a prolific cause of disease, but greatly 
modifies diseases originating from other causes. Ordinarily it exists 
in a dormant or latent state, producing a chronically depraved state of 
health, usually termed dyscrasia; but when it becomes active, as it 
does when other causes have disturbed the comparatively healthy 
balance which the vital force, aided by time, has served to produce, 
or when thrown into activity by the effects of remedial agents, then 
its presence becomes so pronounced that the most prejudiced can- 
not fail to see it. What matters it, then, so we clearly recognize the 
condition itself, whether we call it psora, dyscrasia, chronic blood 
disease, or any thing else? As long as no better name is found 
for it, we have no hesitation in calling it psora, and psora it shall be ! 
" Multa non sunt sicut multis videntur /" 

Diseases can properly be said to be cured, only when the affected 
parts and functions are restored to their original state ; that is to say, 
when the disease is thoroughly eradicated, and its effects entirely 
removed from the system. On the other hand, when diseases, either 
through treatment or otherwise, simply disappear, or become latent, 
without being thoroughly eradicated, they are said to be suppressed. 
It is this suppression of disease, the ordinary result of allopathic 
treatment, which constitutes true psora, as above defined, and is the 
chief cause of nearly every chronic disease. Whenever it becomes 
active, there is generally an effort, so to speak, on the part of nature 



PRACTICE OF MEDICINE. II 

to eliminate it from the system by throwing it to the surface, consti- 
tuting the various forms of tetter, and other itchy eruptions, whence 
the name by which Hahnemann designated the affection, namely, 
psora, a term derived originally from the Greek, and signifying to rub. 

From the foregoing, it is evident that the psora, properly so 
called, is a very different affection, ordinarily, from that single vulgar 
form of it commonly called the itch, to which allopathists would fain 
confine it. The latter is the least significant, as it is the most super- 
ficial, of all its multiplied forms and manifestations, and generally 
depends upon some local cause of irritation; while the former is a 
profound, peculiar, compound morbific element, whose impress is so 
clearly stamped upon almost every form of disease, as greatly to modify 
its character, duration, history and treatment. It is, in fact, as before 
stated, the expression of the difference between the cure and the 
suppression of disease, which has resulted from the general non- 
observance in treatment, from time immemorial, of the true and only 
law of cure, the homoeopathic, which we will now explain. 

It was a discovery of the immortal Hahnemann, that diseases can . 
only be cured by remedies which are capable of producing similar 
diseases in healthy persons. This irrefutable law of nature is ex- 
pressed by the formula, " similia similibus curantur," or like is cured 
by like, a law as simple and beautiful in its expression, as it is 
universal in its application ; and which is destined to revolutionize 
the whole art and science of medical practice. 

This great natural law of cure had suggested itself to several 
early physicians, especially Stahl, whose words are as follows : " The 
received method in medicine, of treating diseases by opposite 
remedies — that is to say, by medicines which are opposed to the 
effects they produce, (contraria contrariis) — is completely false and 
absurd. I am convinced, on the contrary, that diseases are subdued 
by agents which produce a similar affection." (Similia Similibus.) 
— See Introduction to Hahnemann 's Organon. But it was not until 
the brilliant genius of Hahnemann set it forth disclosed in all its 
beauty and perfection, with irrefutable reasoning and the most ample 
illustration, that it began to be generally recognized by the learned 
as the true, unerring, a?id universal law of nature ; while now, it may 
be truly said, there are but few so ignorant and undiscerning, as not 
in some way " to do it homage." 



12 HOMCEOPATHIC 

Experience shows that, agreeably to this law, those medicines 
which, taken in large quantities, produce in healthy organisms symp- 
toms similar to those of the disease, are the therapeutical agents 
that, in small and convenient doses, cure it in the most prompt, 
certain, and permanent manner. Hence it follows, that homoeopathic 
remedies annihilate disease, by exciting in the system a certain 
artificial malady, which so closely resembles the natural one, as to 
destroy the symptoms of the disease to which such relation is 
sustained. 

In order, therefore, to effect a satisfactory cure of any particular 
disease, we have, in the first place, to select from all others that 
medicine whose effects, symptoms, or manner of action, upon the 
healthy organism, most nearly resembles the symptoms of the disease 
which we aim to cure ; and, secondly, to administer it in such form 
and manner, and with such frequency, as experience shows to be 
best adapted to the end in view. The first of these prerequisites we 
shall consider under the head of 

SYMPTOMATOLOGY. 

Symptoms are of two kinds or classes, namely : those belonging 
to natural diseases, called morbid, and those developed by medicinal 
agents, acting upon healthy organisms, termed pathogenetic. Their 
character is essentially the same, and they differ only in degree and 
manner of production. The former are the expression, or represen- 
tation, so to speak, of natural diseases, or maladies ; the latter of 
analogous artificial diseases. The former are arranged in particular 
groups, more or less variable, according to the age, sex, temperament, 
and general constitution of the patient ; the latter in certain other 
groups, more or less similar, according to the nature of the medicine 
producing them, their mode of preparation and administration, and 
the condition and susceptibility of the provers, or those upon whom 
they are made to act. While there are no known medicines capable 
of producing groups of symptoms precisely the same as those of 
natural diseases, many of them furnish groups of striking similarity, 
whereby we are enabled to select, agreeably to the law of " similia" 
such as prove curative in natural diseases. These, when rightly 
selected and administered, never fail of effecting perfect cures ; such 
medicines are therefore called specifics. Hence a thorough knowl- 
edge of the Materia Medica, and especially of the pathogenetic 



PRACTICE OF MEDICINE. 1 3 

symptoms peculiar to the several remedies, and which are termed 
characteristics, is essentially necessary to success in homoeopathic 
practice. Such knowledge can only be acquired by studying and 
carefully noting the effect of medicines on the healthy subject. 
Happily, so far as the production of a true Materia Medica is 
concerned, this work in the vast realm of pathogenetic investigation, 
has already been performed by numerous observers and provers, 
upon whose veracity and accuracy we can implicitly rely. Of these, 
Hahnemann justly stands at the head ; while the names of Stapf, 
Hartlaub, Hering, Franz, Nenning, and a host of others, furnish a 
constellation whose light pales only before that of the illustrious 
founder of the homoeopathic system. 

Notwithstanding all this, it is not to be denied that our Materia 
Medica has already become encumbered with many indefinite and 
unreliable "symptoms " whose presence in our works renders it 
extremely difficult, in many cases, to make a proper selection. 
Hence it becomes necessary in searching for a specific, to carefully 
sift, compare, and weigh the several symptoms, both of the remedy 
and the disease, selecting that which furnishes the most striking and 
perfect resemblance between them, at the same time having regard 
to the following principles : 

i. Symptoms have a relative value only ; that is to say, the patho- 
genetic characteristics of a medicine are of greater or less value, 
only as compared with those which have or have not the same char- 
acteristics ; so that those symptoms, which at one time, or in one 
series of comparisons, have no particular value, may at another 
time be of the greatest importance. Hence no pathogenetic or 
medicinal symptom should be disregarded, or lightly esteemed, be- 
cause common to other remedies, any more than we should be 
justified in neglecting similar symptoms in the treatment of disease. 

2. The totality of the symptoms is the only true indication in the 
selection of the remedy. For although, as before remarked, there 
are no well-recognized pathogenetic groups of symptoms precisely 
the same as those of natural diseases, there are those which bear 
such a striking resemblance to them, as plainly to indicate their reme- 
dial virtues under the law of " sitnilia." But since they are often 
associated with others of a diverse character, it is necessary always 
to have regard to the totality of the symptoms, otherwise the law 
could not justly be said to apply. 



14 HOMCEOPATHIC 

3. A remedy to be perfectly homoeopathic, must be capable of 
producing all those symptoms which are peculiar ', extraordinary and 
characteristic in the natural disease. When this resemblance exists, 
the disease will generally yield to a single dose of the medicine, 
provided the remedy be properly administered, and due attention 
given to hygienic influences. 

4. If a remedy is chosen which is not strictly homoeopathic to 
the disease, that is, to the totality of the symptoms, it will, especially 
in appreciable doses, give rise to symptoms not properly belonging 
to the disease, and therefore referable only to the remedy ; or it will 
have the effect of increasing the morbid symptoms, producing what 
is called homoeopathic aggravation. If, in these cases, the pathogenetic 
symptoms are sufficiently similar to those of the disease, to give the 
remedy a decidedly homoeopathic effect, the disease will, as in the 
former case, generally yield to a single dose of the medicine, pro- 
vided sufficient time be allowed for the homoeopathic aggravation to 
subside. 

THE HOMOEOPATHIC MATERIA MEDICA. 

The homoeopathic materia medica, in its complete form, contains 
such a vast number of symptoms, natural, morbid and pathogenetic, 
that the student is apt to be overwhelmed by their multiplicity and 
unscientific arrangement. I have therefore made a selection, under 
the head of " Characteristic Materia Medica" embracing only such 
pathogenetic symptoms as are peculiar to the several remedies, or 
have been confirmed by clinical experience. Of course, this is not 
intended in any sense as a substitute for our more elaborate works on 
the subject, but simply as an aid to the student in acquiring an easy 
and at the same time definite knowledge of the characteristic symp- 
toms of our principal medicines. A thorough knowledge of these 
symptoms, together with the analytical system of diseases and their 
remedies, will enable any competent person to select, without diffi- 
culty, the true specific for any group of symptoms which may present 
themselves in the course of any disease, either acute or chronic. 
These tables the student will do well to memorize, especially those 
pertaining to the more common and special forms of disease, as well 
as the characteristic indications of the remedies employed. This 
amount of familiarity with the homoeopathic materia medica, and the 
pathogenesis of medicines, is necessary in order to give the required 
coup d'ozil of the symptoms, so that the relation of the remedy to 



Practice of medicine. 15 

the disease may be readily and clearly recognized, and much time 
and suffering, as well as unnecessary labor and research, avoided. 

THE HOMOEOPATHIC DOSE. 

Owing to its extreme minuteness, the efficiency of the homoeopathic 
dose, whether the medicine be exhibited in the first or last attenua- 
tions, has often excited the astonishment of the inexperienced. 
Many ingenious attempts have been made to explain its efficiency ; 
some referring it solely to a dynamic power developed in its prepa- 
ration, and others attributing it simply to dilution. Doubtless, both 
explanations are, to a certain extent, correct ; that is to say, that a 
direct and absolute increase of medicinal energy is produced by 
simple attenuation, while at the same time their peculiar virtues 
are exalted by atomic separation. For, on the one hand, it 
cannot be denied that within certain extreme and indefinite 
limits, bounded only by atomic separation, medicinal substances 
are free to act upon the living organism, only in proportion 
as their ultimate particles, or atoms, are in a condition to be 
brought into the most intimate connection with the living 
tissues; while, on the other hand, it is equally certain, that true 
atomic separation must, from the very nature of the case, set free 
the peculiar medicinal virtue of the substance, and that in direct 
proportion to the amount of atomic separation. So that, practically, 
it makes but little, if any, difference which explanation is received, 
since in both cases, the power or virtue of the medicine, whether 
dynamic or otherwise, is proportionate to the amount of dilution, 
attenuation, or atomization, to which the medicine is subject in its 
preparation. 

For these reasons, we would, as a general rule, recommend the 
employment of the higher attenuations, except when used as blood 
aliments, as antidotes to toxic symptoms, and in specific blood diseases, 
when the size of the dose, or degree of attenuation, should be regu- 
lated by the object in view, and by the exigencies of the case. (See 
the remarks on doses and attenuations under the head of Diphtheria.) 
Some, on the other hand, prefer the high attenuations only in chronic 
diseases, and employ low ones in the acute. But, if the above rea- 
soning be correct — and we can testify that it has been amply verified 
in our own experience — the practitioner has only to repeat the dose 
at sufficiently short intervals, to extinguish promptly and satisfactorily 



1 6 HOMOEOPATHIC 

the most acute symptoms. Cases, it is true, sometimes occur, in 
which the lower preparations seem to yield the best results ; but we 
are satisfied, both by experience and observation, that in the vast 
majority of cases, if sufficient care and judgment be exercised in the 
selection and administration of the remedy, the greatest benefit will 
be derived from the exclusive use of the higher potencies, in nearly 
every simple or non-specific form of disease.* c. p. hart. 

* The student will naturally desire some definite rule or principle by 
which to regulate the potency, or size of dose, in particular cases. In lieu of 
such information, which can only be acquired by long practice and observation, 
the suggestions contained in the following extract from an article of ours, 
entitled " Observations on the Homoeopathic Dose." published in the " Cincinnati 
Medical Advance" for November, 1873, may be of value : 

" But a still more important consideration, affecting the question of dose, 
is the precise pathological condition of the patient. The symptoms, so far as 
casual observation goes, may be the same, and yet different cases, or the same 
case at different times, require either different remedies, or different attenua- 
tions of the same remedy. This is a matter of every day observation, and yet 
it is not sufficiently recognized in our therapeutics. To illustrate : A patient 
is threatened with congestion of the bowels. This presupposes a congested 
state of the portal system. The latter, more particularly, will determine the 
remedy. The former, including, of course, all the minuter elements of 
the case which go to make up the tout ensemble, and especially the matter of 
susceptibility, time and degree, will cceteris paribus, determine the potency or 
degree of attenuation. Thus, the state of greatest congestion short of actual 
effusion, necessarily calls for the higher attenuations, since the lower ones 
will be quite certain to precipitate the condition we wish to avoid. On the 
other hand, slight congestions, contrary to what, at first glance, we might sup- 
pose would be the case, generally require the lower potencies, though the higher 
may answer the purpose ; but the latter will require, of course, to be pushed to 
the point of successful reaction to be effective. The great difficulty in such 
cases, is, to determine the exact pathological condition in question. If the 
tension, so to speak, of the function, or diseased action of the part, is as great 
as nature will bear without a decided change of condition, then the higher 
potencies will be most effective in subduing the symptoms for which they 
are given. On the other hand, using the same term as before, if the tension 
is light or weak, and the diseased function or action of the part is capable of 
a much greater strain, without any essential change in its pathological condi- 
tion other than one of degree, or range of action, then experience shows that 
low attenuations are equally, and in many cases, even more effective than the 
high. In short, the whole question seems to turn upon the facility with 
which, in any given case, reaction is capable of being excited. 

Of course, there are some conditions which stand outside of this law, such 
as chemical, chemico-vital and toxical conditions, which it would be absurd 
in the highest degree to attempt to bring under it; such for example as 
anozmia, in which there is a notable deficiency of haematine in the blood. 
Here iron is required as a nutrient, and hence, cceteris 'paribus, the lower the 
form in which we administer it, the better." 



PRACTICE OF MEDICINE. 1 7 

REPETITION OF THE DOSE. 

The repetition, no less than the volume of the dose, is a subject 
upon which great differences of opinion still exist among 
homceopathists. Some administer the medicine in a single dose, 
generally of a low attenuation, and if no perceptible benefit is found 
to result, they fly immediately to some analogous remedy, or alter- 
nate it with others of a supplementary, or supposed corroborative 
character, as though a curative effect were to be obtained by a direct 
action of the medicine. But no principle of our practice is better 
established, than that cures, properly so called, are never effected 
by the direct action of medicines, but by the reaction of the vital force 
excited by them. (Hahnemann, Org., §§63, 64, 68.) Hence, expe- 
rience shows that, although a single dose of a well-selected remedy 
is often sufficient to produce a healthy reaction, and thus start a 
cure, which, if not interrupted by injudicious interference, mental 
impressions, or errors of diet, will go on to completion ; yet, if the 
disease be severe, so that reaction of the vital force is not easily 
excited, a repetition of doses, at longer or shorter intervals, 
according to the urgency of the case, the nature of the affection, 
and the age, constitution and temperament of the patient, is neces- 
sary in order to produce a salutary effect. The greatest caution, 
however, needs to be observed in the repetition of the dose, as well 
on the one hand to avoid aggravations resulting from excessive 
reaction, as on the other to promote it by a steady pathogenetic 
influence of the vital power, to the extent of a complete subdual of 
the morbid symptoms. Nor should we fail to remember, that a too 
sudden, or a too violent assault on the vital power, even to the point 
of successful reaction, is often attended by unpleasant effects, espe- 
cially if low attenuations are employed, so as in a great measure to 
frustrate the end in view. When, therefore, the vital power rises in 
opposition to the action of the remedy, especially when new symp- 
toms, and not simply aggravations of the old ones, are developed, 
we must allow sufficient time for the excitement to subside, and 
then, if a healthy reaction has taken place, the salutary effect should 
be allowed to continue uninterrupted to its close ; if not, it should 
be steadily but gently stimulated by such repetition of the remedy 
3 



1 8 HOMOEOPATHIC 

as may be found necessary to accomplish it* Of course, the frequency 
of such repetitions will necessarily depend, as before stated, upon the 
nature of the disease, the urgency of the case, and the age, constitu- 
tion, temperament and general condition of the patient. 

As a general rule, we have obtained the best results by dissolv- 
ing twenty or thirty globules of the thirtieth potency in half a tumbler 
of water, stirring it well, and giving a teaspoonful of the solution 
every hour, or oftener, in acute cases, and once or twice a day in 
chronic cases. If aggravations occur, either natural or pathogenetic, 
the medicine should be omitted until they subside, or until it is seen 
what effect, if any, the omission has upon the symptoms, when, if a 
curative action has been fully developed, the medicine already given 
may be found to suffice ; if not, it should be repeated, agreeably to 
the rules and principles already suggested. If the disease be a 
violent one, such as croup or cholera, the medicine should be ad- 
ministered every five, ten or fifteen minutes, according to the urgency 
of the case. In all instances, whenever an amelioration of the 
symptoms takes place, the administration of the medicine should be 
suspended ; but should they recur, or convalescence cease, the 
same medicine should be immediately resumed, or another appro- 
priate one given. Should the salutary effects of the remedy be 
interfered with, or suspended, in consequence of errors of diet, 
cold, or other causes, measures should be adopted to counteract 
the supposed cause of the interference, and as soon as the interrup- 
tion ceases, the original medicine should be at once resumed, and 
the disease guided to a favorable issue agreeably to the principles 
already explained. 

ALTERNATION OF MEDICINES. 

Owing to the great diversity of morbid conditions, and the com- 
paratively limited number of single remedies in every respect 
homoeopathic to them, it often becomes advisable, especially in 
acute cases, to give two, and sometimes three medicines, in alterna- 
tion, whenever necessary to cover the characteristic symptoms of the 
disease. In this way, for instance, in Croup, we sometimes find it 
expedient to give Aconite, Hepar sulph. and Spongia in rapid succes- 



* Jahr, Snelling's Hull's, to which work we are under great and frequent 
obligation. 



PRACTICE OF MEDICINE. 19 

sion, or alternation ; or, after Aconite, the two latter in alternation ; 
or we may have occasion to give Phosphorus and Bromine, in the 
same manner, according as the particular forms and stages of the 
disease seem to require. In the same manner, also, in Erysipelas, 
we give Aconite and Belladonna, or Belladonna and Rhus, or Rhus 
and Phosphorus, according to the various forms and stages of the 
disease. 

Whenever in acute cases it becomes necessary or expedient to use 
two or more medicines in alternation, great care should be taken 
to observe the effect of each remedy upon the symptoms, and one or 
the other of them should be withdrawn, or another more appropriate 
one substituted, as occasion may require. At the same time, equal 
care should be taken not to make such changes unnecessarily, or too 
frequently, bearing in mind the fact, that the production of new 
symptoms, when properly belonging to the disease, or the aggrava- 
tion of old ones, are good signs, and only require that the medicine 
should be withheld, or given less frequently, to produce the most 
favorable results. 

Some practitioners are opposed to the alternation of remedies, 
particularly in chronic cases, but in our opinion without good reason. 
When the medicines selected are truly homoeopathic to the symp- 
toms — and of course no others should ever be used — we are confi- 
dent that we have in this way often been able to abridge the treat- 
ment several weeks, and even months. Thus, in a case of Chronic 
Diarrhoea of over eight months standing, attended by painful 
palpitations of the heart, and which had long resisted single remedies, 
however judiciously administered, we prescribed Petroleum and 
Crocus sat. alternately once a day — Petr. for the diarrhoea, and Croc. 
for the painful palpitations — and within a week the diarrhoea and the 
palpitations both ceased, and there was no return of either. In this 
case China, Ferrum, Calc. c, Petr. Phos., Sulph., and a dozen other 
remedies had been tried singly in vain. 

Another patient, a merchant, had been afflicted for more than 
three years with non-syphilitic ulcers, boils and carbuncles, associa- 
ted with more or less muscular rheumatism, affecting sometimes one 
part of the body, and sometimes another. For this combination of 
symptoms we prescribed Silicea and Bryonia, in alternation, once a 
day, for about a week, when the rheumatism being relieved, we 



20 HOMOEOPATHIC 

withdrew Bryonia, but continued the Si/icea, until the ulcers showed 
signs of amendment, when we withdrew the medicine altogether. In 
the course of a few weeks the ulcerations were entirely healed ; but 
shortly afterwards the rheumatic pains returned with greater violence 
than at first. We then gave a single dose of Bryonia jo, and rested 
the case. In a short time the rheumatism disappeared, and the 
patient's health was fully restored. 

We desire particularly to caution the prescriber against changing 
the medicine in chronic cases on the first appearance of aggrava- 
tions, even when they seem to demand it, as should always be done 
in acute diseases, for such aggravations are much more apt to occur 
in chronic cases, especially when medicines are alternated ; but if 
the medicines given are homoeopathic to the principal symptoms, the 
aggravations will shortly subside, so soon as the vital force has 
become paramount to the disease. All that is necessary in such 
cases is, to diminish the frequency of the doses until the curative 
action is fully established. 

DURATION OF THE ACTION OF MEDICINES. 

Every medicine has a peculiar effect on the living organism, as 
well with respect to its period of action, as to the medicinal symp- 
toms it is capable of producing. As a general rule, the duration of 
action of vegetable remedies is much shorter than that of mineral 
medicines, the former generally lasting only a few hours or days, 
whilst the latter frequently continues many months, and even years. 
Thus, the action of Aco?iite is sometimes limited to a period not 
exceeding half an hour, while, on the other hand, the effects of 
Mercury on the system often extend through months and years, and 
even through life. 

Observation also establishes the fact, that the pathogenetic 
effects of medicines are subject to precisely the same laws of period- 
icity that control diseased action. This gives rise to what are called 
secondary symptoms, in which the primary effect of the medicine is 
frequently followed by one of an exactly opposite character. It also 
produces those medicinal aggravations which are frequently mistaken 
for the exacerbation of natural disease. These aggravations are gen- 
erally found to recur, in most chronic affections, every seven or eight 
days, being more marked on each alternate day or week, until, after 



PRACTICE OF MEDICINE. 21 

the lapse of six or eight weeks, they commonly subside altogether. 
Hence it becomes necessary in many chronic affections, especially 
when medicinal exacerbations occur, not to repeat the remedy oftener 
than once a week, and sometimes not oftener than once in two or 
three, or even once in six or eight weeks, in order not to interfere 
with the healthy reaction of the vital force. In fact the same, rule 
applies in chronic cases of this character, as in those which are acute, 
with this difference, that we measure the interval between the doses 
in the former by weeks instead of hours or days, the period which is 
found to govern the medicinal aggravations determining the repeti- 
tion of the dose in all cases. 

We have hitherto regarded the medicine employed as having been 
rightly selected ; but if otherwise, one of two things will follow ; 
either the medicine will have no perceptible effect whatever upon 
the disease, or it will give rise to symptoms which, not being similar 
to those of the disease, will only add to the discomfort of the patient, 
and if long-continued will greatly aggravate the case. In either 
event, the medicine should be immediately replaced by one whose 
mode of action corresponds more accurately to the ense?nble of the 
malady, and which will at the same time cover the principal symp- 
toms produced by the remedy just omitted. The safest and most 
practical rule to follow in these cases is, to watch attentively the 
moral condition and general aspect of the patient, and if ameliora- 
tion takes place in these particulars, to await the further action of the 
medicine; if not, the state of the patient becoming progressively 
worse and worse in these respects, no time should be lost in seeking 
a more appropriate remedy.* Care should be taken, however, not 
to reject a remedy which has been carefully chosen, whatever may 
be the momentary or occasional character of the aggravations 
depending upon it, until sufficient time has elapsed to observe the 
alternations of good and bad symptoms, which, as before stated, 
should be at least seven or eight days in chronic cases, and from five 
to fifteen or thirty minutes in those which are acute. This rule 
should be followed in every case in which aggravations or secondary 
symptoms are observed ; in every other we should follow the general 
directions already laid down under the head of "repetition of dose." 



* Jahr. 



22 



HOMCEOPATHIC 













TABLE I. - 


-ANALYSIS 










r 


r Weak, 

China. 

Ansemic, 














Ferr. 




r 






r 






m 

o 


' Gland. Swell. 
Iod. Sil. 




i 

1 *5 


Accelerated, 

J.C071. 

Retarded, 






Cold, 






13 - 


Tubercle, 




13 


Digital. 






I>ulc. 








Phos. 




j 


Irregular, 










s 


o 


TettersUlc'rs, 




b 


^Lrsen. 










%-J 


GQ 


Ars. Merc. 










Concussion, 




5 . 

DD 




' Anasarca, 




.2 


Quick, 

Bryonia. 




r 






s 

o 




Arsen. 




rt 


Slow, 




, 






Q 


tJ 


Ascites, 




"Bh 


Castor. 




a 


Exp. to Water 






<x> 


Hell. Merc. 


' 


OQ 


Irregular, 




8) 


or Damp, 


\ 




"73 - 


Adipose, 




PS 


I Opium. 






eg 


Rhus. 






GQ 


Cede. c. 
















Pregnancy, 




. 


Increased, 









m 






Sepia. 




•*3 


Cole. c. 




J ° 7 ' „ ^ 


v 






OB 


Deficient, 


, 


ii 


Cb/ea. 


h 




Emaciated, 


C 




Nux V. 




fl 




* 




China, Ars. 





<: 


Canine, 


*a 


Grief, 


& 




' Infancy, 







China. 


< 


V 


Ignatia. 


fe_ 




Cham. 


ti 


-g f Excessive, 


ill 

M 

5 


K 


b. 




Adolescence, C. - 


0" 


.!: J JLrsew. 


H. 

(H 




Anger, 

Cham. 


03 



•H 

IS 


9? 

60 - 
< 


Puis. Bell. 
Crit, Age, 
Lach., Sepia. 
Old Age, 




•H 


p I None, 
. r Sopor, 


IB 




fe 




Opium. 


^ 


o J Opium. 




ft 

a 


Jealousy, 
Hyoscyamus. 


£ 


f Male, 





=2 1 Sleeplessness, 
L G#ea. 








oq 1 Female, 




-• f Amenorrhea, 

| 1 Pulsatil. 

^ 1 Menorrhagia, 

L Ignatia. 






Chagrin, 

Phos. A. 




1 


Puis. 
Gentle, 












. 


Puis. 










Fright, 

Opium. 




c 
.2 

•S3 - 
o 

o* 


Irascible, 

Nux V. 
Melancholy, 




f Diarrhoea, 

o J ip. Merc. 
-2 ] Constipation, 
00 I Op.Suiph. 










00 


Ignatia. 








Nostalgia, 
Capsicum. 




5 


Cheerful, 

Coffea. 




. ( Scanty, 
c J Canthar. 












Sanguine, 




'J* 1 Copious, 










<u 


Hyos. 












s 


Lymphatic, 
















Lach. 












s 

0> 


Choleric, 














Nux V. 









OF 



PRACTICE OF MEDICINE. 
DISEASE. 



23 



d. <{ 



f I Morning. 

Time >- Evening. 
. I J Night. 

•2 

"I ■¥»•*• 1 Erect. 

> \ Positlon JEecumbent 

- 1 

bC 

if ,, .. I Slow. 

Motlon }Ea P id. 

Kest, Diet, etc. 



' Conditions 

same as above and 



very numerous. 
See 



Mat. Med. 



Eight Side, 

Left Side, 

Morning, 

Evening, 

Day, 

Night, 

Motion, 

Eest, 



Bell. 

Aeon. 

Nux. 

Puh. 

Calad. 

Sidph. 

Bryonia. 

Rhus tox. 



Congestion, 

Bell. 



Fever, 



Aconite. 



Pleuritic Pain, 

Bryonia. 



Emesis, 

Ipecac. 

Cephalalgia, 

Glonoine. 



Cardialgia, 

Nux Vom. 



Vesic. Ervs., 

Bhus lox. 



Psoric Erup., 

Sulph. 



Algidity, 

Arsen. 



Delirium, 

Hyoscy. 



Tremor, 

Arnica. 



Anaesthesia, 

Carbo veg. 



24 HOMOEOPATHIC 

SELECTION OF REMEDIES. 

We have purposely delayed considering the various circumstances 
connected with the proper selection of remedies, until we had dis- 
cussed the different questions connected with their action, in order 
that the relations which they severally sustain to each other might be 
more readily traced and comprehended. For, in order to be able to 
select the most appropriate remedy in any given case, it is not only 
necessary to be well acquainted with the pathogenesis of the several 
medicines, but, as already stated, to keep in view the totality of the 
symptoms, as well as the exciting cause, and other modifying circum- 
stances. Hence, although much, and sometimes everything, depends 
upon the homoeopathicity of the re??iedy, that is to say, the similarity of 
its symptoms to those of the disease, it is no less important to ascer- 
tain the immediate exciting cause of the malady, and to keep in view 
the constitution, age, sex, disposition and temperament of the patient ; 
and also the state of the principal bodily functions, such as the 
respiration and circulation, appetite and thirst, sleep, catamenia, 
stool and urine. In order to obtain a comprehensive view of the 
whole circle of indications referred to, we will present them in tabular 
form, with illustrative examples under each head. It is scarcely 
necessary to remark, by way of explanation, that in these instances 
the examples cited in the table sustain no relation to the other con- 
ditions with which they are associated, but simply to the particular 
symptom or condition under which they are respectively placed; that 
is to say, the selection in this instance not having been made with 
any reference to the general pathogenesis of the several remedies 
mentioned — as would need to be the case in actual disease — are 
simply illustrative of the particular indications with which they stand 
connected in the tables. 

A careful inspection of the foregoing table, will show that some 
of the indications embraced in it should have a much greater in- 
fluence on the selection of the remedy than others. Thus, age, by 
itself, is no criterion for the selection of a remedy, being subordinate 
to every other indication, and is only to be taken into consideration 
when the other symptoms correspond. On the other hand, the 
constitutional condition, as a general rule, is, next to the exciting cause 



PRACTICE OF MEDICINE. 2$ 

of the greatest importance, and often exercises a controlling influence 
upon the selection. Of course, the practitioner is not to lose sight 
of the fact, that the medicine must in all cases be homoeopathic to 
the characteristic symptoms of the disease \ but when these are few 
in number, or not well pronounced, or when the auxiliary symptoms 
are the most prominent, then the selection is made to depend to a 
great extent, and sometimes entirely, upon the latter. Thus, for ex- 
ample, a patient is attacked with symptoms suggestive of incipient 
phthisis, such as a slight hacking cough, occasional slight pains in 
the chest, scanty expectoration of saltish mucus, and suppression of 
the menses. Here, Pulsatilla, by restoring the catamenia, will 
probably effect a cure ; and is preferable to Phosphorus, which, were 
it not for the suppression of the menses, (which in this case is prob- 
ably the exciting cause of the whole difficulty,) would be the most 
appropriate. Indeed, it may be laid down as a general rule, that 
the sexual sphere exerts a controlling influence in nearly all the 
diseases of females, and should therefore never be lost sight of in 
their treatment. In these cases, it is true, the selection is made to 
depend upon a mere function, but it is one the derangement of which 
frequently makes a profound impression upon the system, giving rise 
to many secondary symptoms, and is therefore entitled to the highest 
consideration. 

SUBSTITUTION OF MEDICINES. 

We have already remarked, that no two medicines produce pre- 
cisely the same pathogenetic effects ; whence it follows, that no rem- 
edy can be a perfect substitute for another. But it frequently hap- 
pens in the treatment of disease, that after a medicine has spent its 
action, the symptoms have undergone so little change, as to suggest 
the continuance of the same remedy. In such cases, the happiest 
effects are sometimes produced by the substitution of another, but 
similar medicine. The change in the symptoms, though slight, may 
be sufficient to point out an analogous remedy more pathogenetic- 
ally appropriate ; bur even when this is not the case, the new im- 
pression made upon the symptoms by the minor differences in the 
action of the two remedies, will frequently be found to exert a more 
beneficial effect upon the disease, than would result from the con- 
tinuance or repetition of the original medicine. This is especially 
4 



26 HOMOEOPATHIC 

true of chronic maladies, in which, as already stated, care should 
always be taken to allow sufficient time for the remedy to spend its 
entire force ; after which, though there should be but a mere shade 
of variation produced in the symptoms, there can be no good reason 
for its continuance. Indeed, we would lay it down as an invariable 
rule in such cases, never to repeat the same remedy. The catalogue 
of medicines of similar pathogenetic action is now sufficiently ex- 
tensive, to enable the practitioner to substitute an analogous remedy 
in all cases of this character. The same care, however, is neces- 
sary in the selection of a substitute, and the same rules apply, 
as in the selection of the original medicine, it being a supreme law 
in the use of all homoeopathic remedies, that they should be capable 
of producing symptoms similar to those for which they are given ; 
and, secondly, that they should always be allowed to complete their 
action before being changed. No medicine, therefore, however 
analogous it may be, is ever to be substituted for another while the 
former is still acting, and not then until, by a comparison of all the 
symptoms, its homoeopathicity is clearly established. 

With due observance of the foregoing directions, substitution, 
agreeably to the order of succession contained in the following table, 
will, as a general rule, be found to be the best adapted for consecu, 
tive treatment ; the remedies named as being suitable after others 
being those to which a preference should be given over other medi- 
cines having analogous properties, but which sustain no such re- 
lation to the previous treatment. While, therefore, on the one hand, 
remedies should always be selected with reference to the totality of 
the symptoms existing at the time the selection is made, without re- 
gard to any definite order of succession in their administration, the 
subsequent treatment, on the other hand, should be so conducted 
that their administration shall correspond, as far as possible, with the 
order of succession here given : 



PRACTICE OF MEDICINE. 
TABLE II.— SUBSTITUTION. 



27 



REMEDY. 


SUITABLE AFTER. 


SUITABLE BEFORE. 


Aconite. 


Am. and Sulph. 


Arn., Ars., Bell., Bry., Cann., 
Ipec, Spong., Sulph. 


Alumina. 


Bry., Lach., Sulph. 


Bry. 


Ant. cr. 




Puis, and Mere 


Ant. tart. 


Bar. c. and Puis. 


Bar. e, Ipec, Puis., Sep.,Sulph. 


Arsenicum. 


Aeon., Arn., Bell., Chin., Ipec., 


Chin., Ipec, Nux vom., Sulph. 




Lach., Verat. 


Veratrum. 


Asa fcet. 


Puis, and Thuja. 


Caust. and Puis. 


AURUM. 


Bell., Chin., Puis. 


Puis. 


Belladonn. 


Hep., Lach., Merc, Phosphor., 


Chin., Con., Dulc., Hep., Lach. 




Nitric Acid. 


Plat., Bhus., Stram. 


Bryonia. 


Aeon., Nux v., Op., Rhus. 


Alum, Rhus. 


Calc. carb. 


Chin., Cupr., Nit. ac, Sulph. 


Lye, Nit. ac, Phos., Sil. 


Carbo veg. 


Kali, Lach., Nux v., Sep. 


Ars., Kali, Mere, Phos. ac. 


Causticum. 


Asa f., Cupr., Lach., Sep. 


Sep., Stan. 


China. 


Arn., Ars., Ipec, Merc, Phos. 


Ars., Bell., Carb. v., Pulsatilla, 




ac, Veratrum. 


Veratrum. 


Cuprum m. 


Sulph., Verat. 


Calc, Verat., Sulph. 


Hepar s. 


Bell., Lach., Sil., Spong., Zinc. 


Bell., Merc, Nit. ac, Spong., 

Sil. 
Arn., Ars., Chin., Cocc, Ign., 


Ipecacuan. 


Aeon., Ars., Am., Verat. 






Nux vom. 


Kali carb. 


Lye, Nat. m., Nit. ac. 


Carb.v.,Petro.,Phos.,Khus.,Sul. 


Lachesis. 


Ars., Con., Hep., Lye, Merc, 


Alum., Ars.,Bell., Carb. v.,Caust. 




Nit. ac, Nux v. 


Con., -Dulc, Merc, Nux v., 
Phos. ac. 


Ledum. 


Lycopodium. 


China, Sepia. 


Lycopodium 


Calc, Silicea. 


Graph., Led., Phos., Puis., Sil. 


Mercurius. 


Ant. c, Bell., Hep., Lach. 


Bell., Chin., Dulc, Hep., Lach. 
Nit. ac, Sep., Sulph. 


Nitric acid. 


Bell., Calc, Hep., Kali., Nat. c 
& m., Pulsat., Sulph., Thuja. 


Calc, Petrol., Puis., Sulph. 


Nux VOM. 


Ars., Ipec, Lach., Petrol., Phos. 
Sulph. 


Bry., Puis., Sulph. 


Opium. 




Bry., Calc, Petrol., Puis. 


Petroleum. 


Nit. ac, Phos. 


Nux vomica. 


Phosphorus 


Calc c, Chin., Kali, Kreos., 
Lye, Nux v., Rhus., Sil., 
Sulph. 

Lachesis and Rhus. 


Petrol., Rhus., Sulph. 


Phos. AC. 


China, Fer., Rhus., Verat. 


Pulsatilla. 


Asa f., Ant., Aur., Chin., Lach., 


Asafcet., Bry., Nit. ac, Sep., 




Lycop., Nit. ac, Rhus., Sep., 


Thuja. 




Sulph., Tart., Thuja. 




Rhus. tox. 


Arn., Bry., Calc, Con., Phos., 


Bry., Phos., Phos. ac, Pulsat., 


Sepia. 


Phos. ac, Puis., Sulph. 


Sulph. 




Caust., Led., Merc, Puis., Sil., 


Carb. v., Caust, Puis. 




Sulph., Sulph ac. 




Silicea. 


Calc, Hep., Lye, Sulph. 


Hep., Lach., Lye, Sep. 


Spongia. 


Aeon., Hepar-sulph. 


Hepar sulph. 


Sulphur. 


Aeon., Ars., Cupr., Mere, Nit. 


Aeon., Bell.,Cale,Cupr., Mere, 




ac, Nux v., Puis., Rhus. 


Nit. ac, Nux v., Puis., Khus., 
Sep., Sil. 


Thuja. 


Nitric acid. 


Nitr. ac, Puis. 


Veratrum. 


Ars., Chin., Cupr., Phos. ac 


Ars., Arn., Chin., Cupr., Ipec. 



28 HOMOEOPATHIC 

EXTERNAL APPLICATIONS. 

Great difference of opinion still exists among homoeopathists in 
relation to the extent, propriety and usefulness of external applica- 
tions in the treatment of disease. Hahnemann himself regarded 
them as extremely prejudicial, both in acute and chronic cases, 
even when the applications were strictly homoeopathic to the disease; 
and for the following reasons : (See Org. §§ 185 — 206.) 

1. They are unnecessary. If the remedy is truly homoeopathic 
to the morbid symptoms, the disease will be cured by its internal use 
alone, if rightly managed. 

2. They are deceptive. " For the simultaneous application of a 
remedy internally and externally, in a disease where the principal 
symptom is a permanent local evil, brings this serious disadvantage 
with it — the external affection usually disappears faster than the in- 
ternal malady, which gives rise to an erroneous impression that the 
cure is complete, or at least it becomes difficult, and sometimes im- 
possible, to judge whether the entire disease has been destroyed or 
not by the internal remedy." 

3. They are injurious. For if the local symptoms are not sup- 
pressed, as they are likely to be by local applications, " they may 
lead to the discovery of the homoeopathic remedy suitable to the en- 
tire malady ; this remedy once discovered, the continued existence 
of the local affection would show the cure was not yet perfected, 
while its disappearance would prove that the evil had been extirpa- 
ted to its very root, and the cure absolute." 

Our own opinion, fortified by experience, is this : — If the disease 
is highly acute, and the local symptoms very distressing, local rem- 
edies, of a truly homoeopathic character, are always safe and bene, 
ficial ; safe, because, being homoeopathic to the symptoms, they can 
only act in harmony with nature ; and beneficial, because the symp- 
toms in such cases are always sufficiently well pronounced, to render 
any mistake in the selection of the proper curative agents unneces- 
sary, while they often contribute greatly to the relief and comfort of 
the patient. 

On the other hand, in the treatment of chronic maladies, local 
applications, as a general rule, are less necessary for the comfort of 



PRACTICE OF MEDICINE. 29 

the patient, less promotive of recovery, and much more apt to be 
attended by the evil consequences apprehended by Hahnemann. 
Hence we seldom make use of them in diseases of long standing, 
whether general or partial, but depend entirely upon internal treat- 
ment, which alone is capable of producing permanent and satisfac- 
tory results. 

HOMOEOPATHIC REGIMEN. 

Under this head we propose to point out, in a general way, the 
several kinds of food, drink, and external influences, which are and 
which are not allowable under homoeopathic treatment. It is evident 
that as the homoeopathic dose is exceedingly minute, everything 
should be excluded from the regimen, that is capable of exercising 
any medicinal influence upon the patient, however small. Hence, 
coffee, green tea, spiced chocolate, beer, wine, rum, gin, punch? 
vinegar and other acids, spices, medicinal roots and herbs, fat meat, 
especially pork, strongly seasoned viands and sauces, ice-cream and 
pastry flavored, old cheese, rancid butter, pickles, ducks, geese, and 
young veal, perfumery and other odorous preparations, as they al 
act more or less medicinally, should be entirely prohibited during 
treatment, and for some time afterwards. On the other hand, all 
ordinary articles of diet, both solid and liquid, not included in the 
above list, and not too highly seasoned, may be used with moderation, 
at proper intervals. 

In addition to the observance of suitable dietetic instructions, the 
practioner should enforce proper hygienic regulations. Among these 
may be mentioned, the avoidance of long-continued confinement in 
close rooms, late hours, too much or two little sleep, unchaste habits, 
the reading of sensational or obscene literature, excessive labor, 
either bodily or mental, insufficient ventilation, sedentary or un- 
healthy occupations, and, in fine, everything which can act injurious- 
ly upon the health or retard the recovery of the patient. 

Tobacco, in all its forms, not only antidotes homoeopathic medi- 
cines, but, by lowering the tone of all the vital functions, greatly un- 
dermines the health, producing dyspepsia, hemorrhages, cardialgia, 
gastralgia, general debility, and many forms of visceral disease ; at 
the same time it acts powerfully upon the brain and nerves, derang- 
ing their action, and consequently the functions depending upon 



30 H0MCE0PATHIC 

them. Hence, persons addicted to the excessive use of tobacco, 
are almost always subject to palpitations of the heart, vertigo, head- 
ache, weakness of the limbs, dimness of vision, loss of appetite, dis- 
turbed sleep, and general nervous prostration. 

Coffee and green tea also act in a similar manner, and if used 
immoderately and in great strength, sometimes give rise to conse- 
quences scarcely less pronounced, or less serious. Both of these 
beverages contain nitrogen in large quantity, which overstimulates the 
brain and nerves, producing sur-excitation of the senses, and followed, 
sooner or later, by a corresponding depression of the nervous system, 
giving rise to a large train of functional disturbances, and greatly 
impairing the general health. Black tea, on the contrary, if pure, 
is not injurious to homoeopathic preparations, and being far less 
stimulating than the green, may be used in moderation, in most 
cases, without injury ; but even this should be denied if it excites the 
nerves of the patient, as it does of some very sensitive organizations, 
especially when not accustomed to its use. 

Instead of coffee and tea, water and fresh milk, or cocoa and 
milk, may be used ; and in cases demanding increased nourishment, 
clear milk, warm from the cow, is a beverage of the most wholesome 
character, alike suited to children and to adults. Cocoa shells, also, 
as well as pure chocolate, furnish a pleasant and refreshing beverage. 

It follows that spirituous and malt liquors, as well as the 
so-called galenical preparations of the apothecary, are exceedingly 
pernicious, and should never be resorted to except in extreme cases; 
and even then, none but the purest wine or brandy should be used, 
greatly diluted, and in quantities so small as not to be followed by 
any marked reaction. In cases demanding it, a teaspoonful or two 
of sherry wine, or half that quantity of pure brandy, may be given in 
broken doses, properly diluted, but its effects upon the system will 
need to be carefully watched, and undue stimulation avoided. 

The habitual use of spirituous liquors, even in moderate quanti- 
ties, congests and inflames the lining membrane of the stomach, 
weakens digestion, and impairs, to a greater or less extent, the vital 
functions. Hence it sometimes becomes necessary in such cases, to 
raise somewhat the general tone of the system before the beneficial 
effects of medicines can be obtained. This can generally be best 



PRACTICE OF MEDICINE. 31 

affected, by giving wine or brandy in small quantities, largely diluted, 
being careful to observe the precautions above-mentioned. Persons 
enfeebled by old age, also, sometimes require similar treatment, be- 
fore the system will respond satisfactorily to the action of medicines. 
This careful and judicious use of pure liquors, for medicinal pur- 
poses, is a very different thing from the indiscriminate and almost 
unlimited use of it under allopathic treatment, and still more, the 
fearful abuse of it as a general beverage, which such practice has 
tended to confirm. 

As to malt liquors, though of undeniable benefit at first, in some 
cases of emaciation and debility, especially during convalescence from 
exhausting diseases, they are apt to derange the stomach, particu- 
larly if the digestive organs are enfeebled, and, by congesting the 
portal system, to increase the derangements and the weakness foi 
which they are prescribed. They should, therefore, be used with 
the greatest caution, and always tentatively, bearing in mind their 
stimulating qualities, and their tendency to produce hepatic en- 
gorgement. Nevertheless, to persons accustomed to their use, es- 
pecially industrious laborers, we should not hesitate to allow a single 
glass of pure beer, whenever such an amount of stimulation is not 
otherwise contra-indicated. 

Soda-water, when properly made and flavored, is a pleasant and 
cooling beverage, acceptable to the stomach, and wholesome to the 
system. Fresh sweet cider and lemonade are also pleasant drinks, 
and not injurious during the heat of summer, if used in moderation ; 
but, owing to their acid qualities, they should be strictly forbidden 
while the patient is under homoeopathic treatment. 

We have already indicated, in a general way, the various kinds 
of solid food which may properly be allowed to convalescents, and 
to a limited extent while under treatment; but preference should 
always be given to such as are the most nourishing and easy of 
digestion. 

Fresh oysters are very easy of digestion, and so is wild game, 
such as squirrels, quails, rail birds, rabbits and venison. Partridges, 
wild ducks and common fowls, if not too old and tough, or too young, 
are of comparatively easy digestion, but do not suit all stomachs. 
Young and tender beef is always very digestible and nourishing, and 



32 HOMOEOPATHIC 

stands at the head of every kind of animal food. Mutton is not 
quite so easy of digestion as beef, but is very wholesome, and es- 
pecially useful whenever there is any tendency to dysentery or 
chronic diarrhoea. Veal is less easy of digestion than mutton, es- 
pecially if very young, besides having a tendency to cause diarrhoea; 
it should therefore be used very sparingly, particularly in the 
summer season. Pork, from the fineness and closeness of its grain 
and the amount of fat associated with it, is the most difficult of 
digestion of all the meats, besides being more stimulating and less 
nutritious. Its use should be totally interdicted to all but laborers ; 
and the health of the people would be greatly benefited if it were 
entirely banished from civilized life. 

Scale fish, such as trout, perch, haddock, shad, bass, flounders, 
whitefish, carp, blackfish, pike and codfish, when fresh, are easy of 
digestion, and being rich in phosphorus, are well suited to consump- 
tives, and persons suffering from nervous weakness. Eggs, also, are 
very nutritious, and when properly cooked, are of easy digestion. 
They should either be soft-boiled, poached, or scrambled. 

Vegetable food, from the absence of nitrogen, is less stimulating 
than animal food, and therefore better suited to the summer season, 
hot climates, and plethoric persons. It is also better adapted to the 
earlier stages of acute diseases, and, indeed, is the only kind of diet 
that is generally admissable at such times. From its favoring a 
gentle disposition, it should always be prescribed when the temper 
is irascible and violent. Being less subject to putridity than animal 
food, it is better suited to a scorbutic condition of the system ; but 
on account of its greater tendency to cause acidity, flatulency and 
stomachic weakness, it should be sparingly used in all cases likely to 
be injuriously affected by such qualities. Graham bread, rye mush> 
oat meal pudding, rice pudding, boiled grits, and stewed prunes and 
peaches, are not only nourishing and easy of digestion, but are par- 
ticularly adapted to a dry and feverish state of the system, especially 
when attended with constipation. Farina, tapioca and sago are ex- 
cellent articles of diet during the earlier stages of acute diseases, being 
less stimulating than most other kinds of food, and better tolerated 
by the stomach. 



PRACTICE OF MEDICINE. 33 

The following dietetic regulations should be observed at all times, 
whether in health or sickness : 

i. No food is fit to be eaten that is not sound and fresh ; that is, free 
from disease and decay. Rotten vegetables and putrid meat are 
prolific sources of disease, and should always be rejected. 

2. Food should be properly and sitfficiently cooked; that is, not too 
highly seasoned, nor simply parboiled or watersoaked, but so cooked 
as to leave it tender, juicy and nutritious. 

3. // should always be eaten with deliberation, and well masticated ; 
not bolted down in large masses, which is a very common cause of 
dyspepsia, and the numerous ills connected with it. 

4. Food should be taken into the stomach only at proper intervals. 
The habit of eating at any and all times is very injurious to health. 
The stomach needs rest ; and to get it not more than two or three 
meals a day should be permitted. Invalids and valetudinarians 
sometimes require to partake of food more frequently ; but in such 
cases the quantity should be correspondingly diminished. 

5. No one should ei>er eat to the point of satiety or repletion. When 
the stomach is too much distended, digestion is slow and difficult ; 
and disorder of both the stomach and bowels is not an unusual con- 
sequence of indiscretion. 

6. Lastly, and as a general rule, no one should eat exceptitig when 
he is hungry, and should stop eating as soon as the sense of hunger is 
relieved. This is a cardinal rule of dietetics, and should be observed 
by every one who is desirous of maintaining the integrity of his 
digestive organs unimpaired, or who aims to recover their tone and 
efficiency after they have lost them. 

MEDICAL NOMENCLATURE. 

Besides being divided into acute and chronic, diseases are dis- 
tinguished as either general, partial or local. This classification, 
though not founded upon any definite and well-grounded pathological 
distinction, possesses considerable convenience for purposes of refer- 
ence, and we shall therefore avail ourselves of it in the description of 
diseases. 

That the distinction just mentioned is not well-founded, we have 
only to instance the subject of fever, as treated in allopathic works, 
where it is divided into as many different forms as there are types of 
the disease, predominance of symptoms, or supposed causes for its 
production. Thus we have inflammatory, typhous and typhoid fever, 
fever beginning as sthenic or inflammatory, and ending as asthenic or 
adynamic, intermittent, remittent and continued, cerebral, hepatic, 
gastric, or gastro-enteric, hectic, and so on, almost ad infinitum; what 
better illustration could we have of the absurdity of the old-school 
method of treating diseases by names, instead of recognizing them 
by their true distinctive characters — the symptoms — which is in fact 

5 



34 HOMOEOPATHIC. 

the only practical method of distinguishing them, as allopathists 
themselves are compelled to admit, when they come to the consider- 
ation of the special forms of disease. And yet, when we make use 
of the only rational method of treating disease by symptoms, instead of 
names, they hasten to cry out, absurd. Well may we respond, "O 
consistency, thou art a jewel/" 

We thus see, in marked contrast, not only the propriety of our 
method of practice, but the absolute necessity that exists for studying 
well the entire group of morbid symptoms in every individual case of 
disease, and not from a few predominant symptoms that force them- 
selves upon the attention of the most casual observer, adopt the 
convenient but indefinite and unsatisfactory method of classifying 
diseases under some of their many appellations, and then treating 
them in the usual routine manner by name. This is, indeed, a very 
convenient method for those who are too indifferent or too lazy to 
study, and are only anxious, by pandering to the prejudices of the 
multitude, to cover their ignorance under the cloak of learning. But 
this course will neither satisfy the conscientious physician, nor will it 
yield creditable results. Nothing short of a careful study and com- 
parison of all the symptoms, will demonstrate the infinite variety of 
diseased action, or enable the practitioner to adapt his remedies in- 
telligently to its many forms, in conformity to the great and unerring 
law of cure. 

If, therefore, we shall so far yield to the common notions of 
disease, as to describe some of its principal varieties under the 
names by which they are generally known, we wish it to be distinctly 
remembered that we do so only for the sake of convenience, and not 
because we subscribe to the correctness of the nomenclature. Disease 
cannot be correctly classified by any combination of technical terms. 
It is correctly written only on the face of nature itself, by the multi- 
plied and ever-varying symptoms which characterize it. Presumptious, 
indeed, must that man be, whatever may be his claims to erudition, 
who attempts to portray in words the multiform phases of disease, 
and present them to us under the mantle of a learned nosology, as a 
full and correct delineation of disease. For ourselves, we shall 
attempt nothing of the kind. A few of the more prominent and 
common forms will be described, so far as the aid of such lights as 
recent pathology has shed upon them will permit; but we desire 
emphatically to admonish the student, that a knowledge of disease 
can by no means be obtained alone from books; and that the 
highest use to which they can be applied, is to serve as guides to its 
successful study at the bedside of the patient. 



PRACTICE OF MEDICINE. 35 



CHAPTER I. 



DISEASES OF THE ENCEPHALON. 



PRELIMINARY OBSERVATIONS. 

The cerebral affections which we propose to consider in 
this chapter are those of a vascular, nervo-vascular, and in- 
flammatory character — those which consist chiefly in a dis- 
turbance of the mental functions will be reserved for another 
place. 

The former include anaemia and hyperaemia of the brain 
and its membranes ; conditions the existence of which some 
pathologists still regard as absurd and impossible, but which 
we shall assume have been amply verified by abundant phy- 
siological, clinical, and necroscopical evidence. 

The question which formerly excited such acrimonious dis- 
cussion, namely, whether the amount of blood in the cranial 
cavity is always the same, has, we think, been satisfactorily 
determined in the negative by recent physiological experi- 
ments ; so that the existence of both cerebral anaemia and 
hyperaemia is no longer a matter of doubt, but must be re- 
garded as of frequent occurrence. 

Before entering more fully upon the description of these 
conditions,we shall introduce a couple of analytical tables em- 
bracing the principal cerebral regions and sensations, together 
with the remedies which, irrespective of other relations, are 
chiefly indicated. 



36 



TABLE IIL— CEREBRAL REGIONS. 



Asafoetida 

Belladonna 

Bryonia 

Cantharis 

Causticum 

Cina. 

Digitalis 

Drosera 

Ignatia 

Plumbum 

Sabina 



Aoid. Phos. 

Alumina 

argentum 

cocculus 

colchicum 

phosphorus 

RH 8 TOX. 

Sabadilla 
Sanguinaria 
Spongia 
Sulphur 



Acid. mur. 

Aconitum 

Agaricus 

Anacardium 

Ant. crudum 

Arnica 

Camphora 

China 

Crocus 

Euphrasia 

Graphites 

Hepar sulph. 

Helleborus 

Hyoscyamus 

Kali carb. 

Lachesis 

Lycopodium 

Natr. carb. 

Nux vomica 

Pulsatilla 

Silicea 

Spigelia 

Stannum 

Staphysagria 

Thuja 



Acid. nit. 

Ambra 

Argent. 

Arnica 

Asarum eu. 

Capsicum 

China 

Colocynth 

Crocus 

Digitalis 

Euphorb. 

Iodium 

Platina 

Rhododen. 

Sambucus 

Sepia 

Aconite 
Ant. or. 
asafoetida 
Camphora 

ClCUTA 
ClNA 

Cocculus 
Cuprum 
Merc. sol. 
Petroleum 
Ehus. tox. 
Sec cor. 
Spigelia 
Spongia 
Stramonium 

Aurum 

Baryta 

Belladonna 

Bryonia 

Calcarea 

Cannabis 

Carb. veg. 

Dulcamara 

Drosera 

Euphrasia 

Ferrum 

Helleborus 

Hyoscyamus 

Ignatia 

Lachesis 

Nux vom. 

Plumbum 

Pulsatilla 

Sabina 

Staphysagria 

Sulphur 

Verat. alb. 



Aconite 

Ant. cr. 

Arnica 

Arsenicum 

Asafoetida 

Asarum eu. 

Belladonna 

Bryonia 

Camphora 

China 

Cina 

Cocculus 

Colocynth 

Crocus 

Digitalis 

Drosera 

Dulcamara 

Glonoine 

Helleborus 

Hyoscyamus 

Ignatia 

Ipecac. 

Mercurius 

Natr. mur. 

Nux vom. 

Platina 

Plumbum 

Pulsatilla 

Rhododend. 

Sabina 

Sepia 

Silicea 

Spigelia 

Spongia 

Staphysagria 

Atomina 

argentum 

AURUM 

Baryta 

Capsicum 

Cicuta 

COFFEA 

Gelseminum 

Rhus. tox. 

Verat. alb. 

Ambra 

Anacardium 

Calcarea 

Cannabis 

Cantharis 

Carb. veg. 

Causticum 

Chamomilla 

Colchicum 

Conium 

Cuprum 

Euphrasia 

Ferrum 

Graphites 

Iodium 

Kali carb. 

Lycopodium 

Opium 

Phosphorus 

Sambucus 

Stannum 

Sulphur 

Zincum 



China 

Cimicifuga 

Colchicum 

Glonoine 

Ignatia 

Moschus 

Nux vom. 

Pulsatilla 

Rhus tox. 

Spigelia 

Spongia 

Aconite 

Argent um 

Asarum eu. 

Belladonna 

Bryonia 

Camphora 

Cannabis 

Cantharis 

Carb. veg. 

Cicuta 

Digitalis 

Gelseminum 

Hyoscyamus 

Lycopodium 

Merc sol. 

Opium 

Petroleum 

Sanguinaria 

Sabina 

Stannum 

Acid. phos. 

Anacardium 

Arnica 

Asafoetida 

Aurum 

Baryta 

Calcarea 

Capsicum 

Coffea cr. 

Crocus 

Cuprum 

Drosera 

Euphrasia 

Helleborus 

Ipecacuan. 

Platina 

Rhododend. 

Sambucus 

Staphysagria 

Sulphur 

Thuja 

Verat. vir. 



temples. vertex 



Acid. phos. 
Argentum 
China 
Rhus tox. 

Aconite 

Arnica 

Asafcetida 

Asarum eu. 

Cannabis 

Cantharis 

Capsicum 

Chamomilla 

Cina. 

Cocculus 

Cuprum 

Digitalis 

Euphrasia 

Helleborus 

Hepar sulph. 

Tgnatia 

Lachems 

tfHEUM 

Rhododend. 

Sabina 
Spigelia 
Spongia 
Staphysagria 

Acid. nit. 

Agaricus 

Alumina 

Anacardium 

Ant. crud. 

Belladonna 

Bryonia 

Calcarea 

Camphora 

Conium 

Opium 

Phosphorus 

Stannum 



Ambra 

China 

Cimicifuga 

Cocculus 

Cuprum 

Glonoine 

Helleborus 

Lachesis 

Stramonium 

Thuja 

Verat. alb. 

Acid. phos. 

Arnica 

Cina 

Gelseminum 

Iodium 

Nux VOM. 

Phosphorus 

Spigelia 

Aconitum 

Anacardium 

Ant. crud. 

Argentum 

Asafoetida 

Asarum eu. 

Aurum 

Belladonna 

Bryonia 

Cannabis 

Cantharis 

Capsicum 

Causticum 

Coffea cr. 

Colocynthia 

Conium 

Crocus 

Euphrasia 

Ferrum 

Graphites 

Ignatia 

Ipecacuan. 

Platina 

Sabina 

Sambucus 

Sepia 

Silicea 

Spongia 

Stannum 

Staphysagria 

Sulphur 



TABLE IV.— CEREBRAL SENSATIONS. 



37 



Aconitum 
Arnicum 
Belladonna 
Bryonia 
Calcarea 
Gelsemin- 
'lonoine 
Helleborus 
Ipecacuan 
Lycopod 
Merc- sol- 
Nux vom- 
Petroleum 
Pulsatilla 
Rhus tox- 
Silicea 
Sulphur 

Alumina 

Cantharis 

China 

Euphrasia 

Ignatia 

Sepia 

Stannum 

Stramonium 

Verat- vir- 



Acid nit. 

Camphora 

Causticum 

Coffea cr. 

Digitalis 

Drosera 

Dulcamara 

Hyoscyamus 

Nat. mur. 

Phosphorus 

Plumbum 

Valeriana 



PAIN.* 



Aconitum 

Alumina 

Apis 

Arnica 

Belladonna 

Baryta 

Bryonia 

Calcarea 

Cantharis 

Chamomil- 

China 

Cimicifuga 

Coffea cr- 

Colocynth- 

Conium 

Glonoine 

Hyoscyam 

Ignatia 

Mux vom- 

Opium 

Silicea 

Spigelia 



Acid mur- 

Ant- cru. 

Arsenicum 

Cocculus 

Ipecacuan. 

Lycopodium 

Nat- carb- 

Nat- mur. 

Rhus tox- 

Stramonium 

Sulphur 



Acid phos. 

Crocus 

Cuprum 

Helleborus 

Iodium 

Lachesis 

Mercurius 

Plumbum 

Sepia 

Valeriana 



Aconitum 

Belladonna 

Bryonia 

Chamomil. 

Cicuta 

Carb- veg- 

Conium 

Digitalis 

Dulcamara 

Ferrum 

Ipecacuan- 

Lycopod- 

Mercurius 

Nux vom, 

Pulsatilla 

Phosphorus 

Sabina 

Spongia 

Staphysag- 

Silicea 

Verat- alb- 



Acid nit- 
Acid phos- 
Agaricus 
Alumina 
Arsenicum 
Cactus 
Camphora 
China 
Cimicifuga 
Cocculus 
Coffea cr- 
Cuprum 
Drosera 
Glonoine 
Helleborus 
Hyoscyamus 
Ignatia 
Nat mur- 
Opium 
Petroieum 
Plumbum 
Spigelia 
Stannum 



Arnica 

Asai'cetida 

Cannabis 

Crocus 

Calcarea 

Causticum 

Euphrasia 

Kali carb. 

Platina 

Sec. cor. 

Stramonium 

Sulphur 

Thuja 



* Tearing or 

Stinging. 



PRE88UKB. 



Aconitum 

Arnica 

Belladonna 

Bryonia 

Calcarea 

Capsicum 

China 

Cimicifuga 

Nat- mur- 

Nux vom- 

Spigelia 

Acid nit. 

Acid phos. 

Asafcetida 

Asarum eu. 

Arsenicum 

Chamomilla 

Cocculus 

Ignatia 

Ipecacuan 

Petroleum 

Pulsatilla 

Sulphur 

Valeriana 



Acid mur, 

Ambra 

Argentum 

Anacardium 

Aurum 

Camphora 

Causticum 

Carb. veg. 

Cannabis 

Capsicum 

Cicuta 

Cina 

Coffea cr. 

Crocus 

Digitalis 

Helleborus 

Hyoscyamus 

Iodium 

Lachesis 

Mercurius 

Natr. carb. 

Phosphorus 

Platina 

Rhododendron 

Sepia 

Silicea 

Stannum 

Staphysagrla 

Zincum 



Aconitum 

Arnica 

Belladonna 

Bryonia 

Cannabis 

Conium 

Gelsemin- 

Glonoine 

Lycopod- 

Natrum 

Nux vom- 

Petroleum 

Phosphor. 

Rhus- tox- 

Sec cor- 



Acid nit. 

Apis 

Cactus 

Calcarea 

Camphora 

Carb. veg. 

Cocculus 

Digitalis 

Graphites 

Ipecacuan. 

Mercurius 

Moschus 

Nat. mur. 

Opium 

Pulsatilla 

Spigelia 

Staphysagria 

Stramonium 

Sulphur 

Thuja 

Verat. alb. 



Ambra 

Arsenicum 

Baryta 

Cannabis 

Cantharis 

Causticum 

Chamomilla 

China 

Cicuta 

Coffea cr. 

Crocus 

Cuprum 

Drosera 

Euphrasia 

Helleborus 

Hepar. sulph. 

Hyoscyamua 

Nitrum 

Platina 

Plumbum 

Stannum 

Zincum 



RUSH OF BLOOD. 



Aconitum 

Belladonna 

Bryonia 

Cactus 

Cannabis 

China 

Calcarea 

Carb- veg 

Colocynthis 

Ferrum 

Gelsemin- 

Glonoine 

Graphites 

Hyoscyam. 

Lycopod- 

Mercurius 

Nux vom- 

Opium 

Plumbum 

Pulsatilla 

Phosphorus 

Rhus tox- 

Sepia 

Silicea 

Sulphur 

Spongia 

Stramon. 

Verat- vir- 

Acid. nit. 

Agaricus 

Alumina 

Ambra 

Apis 

Arsenicum 

Camphora 

China 

Cocculus 

Coffea cr. 

Cuprum 

Drosera 

Helleborus 

Hyoscyamus 

Ignatia 

Lachesis 

Nat. mur. 

Opium 

Piumbum 

Ranunculus 

Ratanhia 

Senega 

Senna 

Tartarus 

Valeriana 

Verat. alb. 

Zincum 

Ant. crud. 

Arnica 

Baryta 

Cantharis 

Causticum 

Digitalis 

Iodium 

S^phyMgrl* 



38 DISEASES OF THE ENCEPHALON. 

ANJEMIA OF THE BRAIN * 

Cerebral Anaemia is a disease of such comparatively rare 
occurrence, that it would scarcely merit separate considera- 
tion, were it not that the similarity of its symptoms to those 
of cerebral hyperaemia renders it liable to be mistaken for 
that condition — an error of very grave importance in diseases 
of the brain, even under homoeopathic treatment. 

The disease consists either in a diminished supply of blood 
circulating in the brain, {hyposmia vel ancemla stride sic dic- 
tus,) or in the cerebral circulation being deficient in haema- 
tine, (kydrcemia,) or in both, {liypcemia et hydtcemia) The first 
may be referred to whatever cause impedes the flow of blood 
to the brain, to contraction of the cerebral vessels by spasm 
or otherwise, or by any other condition whereby the inter-cra- 
nial space is lessened ; the second, to the various causes which 
produce impoverishment of the blood, and give rise to general 
anaemia ; and the last to sanguineous losses, which when con- 
siderable always produce both paucity and poverty of the 
circulating fluid. 

SYMPTOMS. These vary considerably according as the anae- 
mia is gradually or suddenly produced. When it occurs grad- 
ually, the symptoms at first are similar to those of the op- 
posite condition of hyperaemia, namely : great excitement 
of the cerebral functions, headache, flashes of light, confu- 
sion of sight, humming in the ears, vertigo, loss of memory, 
and sometimes convulsions. At a later period, if the disease 
goes on unchecked, symptoms of paralysis may supervene. 

When, on the other hand, cerebral anaemia sets in suddenly, 
as in flooding, traumatic haemorrhages, and other rapid losses 
of the sanguineous fluid, the symptoms presented are those of 
syncope, namely : loss of consciousness, of the senses, and of 
voluntary motion, accompanied with a retarded pulse and res- 
piration, and frequently with slight convulsions. 

DIAGNOSIS. The greatest care is necessary, especially with 
children, to distinguish this state from that of cerebral con- 
gestion. When caused by debilitating losses, and especially 

* See American Horn. Observer, vol. vii., p. 55. 



ANEMIA OF THE BRAIN. 39 

when associated with general anaemia, or with an impaired 
state of the assimilative functions, the history of the case, 
together with the fact that the symptoms of cerebral anaemia 
generally diminish or disappear in the recumbent position, 
will serve to distinguish it from hyperaemia of the brain. 

However induced, cerebral anaemia is always attended with 
great danger to life, especially with children, though when 
early recognized, and promptly and correctly managed, the 
disease, even in its acute form, will generally yield to the 
following 

TREATMENT. In simple syncope,all that is generally requir- 
ed in the way of treatment is, to lay the patient in a horizontal 
position, and thus favor a return of blood to the brain If, 
however, the fainting is of frequent recurrence, it will com- 
monly be found to depend upon some other affection, against 
which the treatment will need to be specially directed. 

THERAPEUTIC INDICATIONS. 

Arsenicum. Violent headache, humming in the ears, ob- 
scuration of sight, particularly on raising the head, vertigo, 
loss of consciousness, pale, chlorotic colored face, great weak- 
ness and prostration, impaired memory, syncope. 

This remedy is eminently homoeopathic to cerebral anae- 
mia ; and is well suited to cases which are complicated or ag- 
gravated by the injudicious use of Ferrum. Care should be 
taken not to use Arsenicum low in this disease. I have gen- 
erally obtained the best results from the 30th potency. 

Calcarea carb. Throbbing, hammering headache, accom- 
panied with great physical prostration, paleness of the face, 
cold hands and feet, and mental weakness, vertigo, loss of 
consciousness, frequent fainting fits, suspension of the senses, 
palpitation of the heart, shortness of breathing, 

This remedy is well suited to general as well as cerebral 
anaemia. 

Camphora. Vanishing of the senses, vertigo, violent throb- 
bing headache, embarrassment of the circulation and respir- 
ation, pale cold skin, spasms and convulsions. 



40 DISEASES OF THE ENCEPHALON. 

Hahnemann says of this remedy : "Vertigo, loss of con- 
sciousness, and coldness of the body, appear to be primary 
treatment of a dose of Camph., and point to a diminished 
afflux of the blood to those parts which are distant from the 
heart ; whereas, the rush of blood to the head, heat in the 
head, &c, are symptoms denoting a reaction of the vital pow- 
ers, just as forcibly as the former symptoms denoted their 
diminished action." 

The action of this remedy is so evanescent as to require it 
to be given in rapidly repeated doses , it is therefore best 
suited to those cases of cerebral anaemia which take the form 
of syncope, especially when caused by the loss of blood. 

China. Headache, especially in the morning, mental weak- 
ness, vertigo, especially on raising the head, obscuration of 
sight, humming in the ears, fainting fits, pale cold face, cold- 
ness of the hands and feet, great debility, with tingling, trem- 
bling or twitching of the muscles and limbs. 

This remedy is best suited to those cases of anaemia caused 
by the excesssive loss of animal fluids. 

Cina. Violent headache,which increases by reading or men- 
tal effort, dizziness, obscuration of sight, faintness, which is 
relieved by lying down, paleness of the face, convulsions, par- 
alytic lameness. This remedy is especially suited to chil- 
dren, particularly where there is any suspicion that the symp- 
toms are caused by verminous irritation. 

Ipecacuanha. Violent headache, excited and aggravated by 
stooping, vertigo with temporary loss of consciousness, pale 
face, cold hands and feet, nausea, with or without vomiting, 
sweet or bitter taste, convulsive twitchings of the limbs. 

This remedy, also, is well adapted to children, and likewise 
to cases resulting from the loss of animal fluids. 

Nux Vomica. Headache, especially in the morning, men- 
tal weakness, vertigo, with obscuration of sight and whizzing 
in the ears, loss of consciousness, syncope, sleeplessness, fright- 
ful dreams, constipation, coldness of the whole body, spasms 
and convulsions. 

This remedy is best suited to cases attended with constipa- 
tion, and like Arsenicum should always be used high. 



CEREBRAL HYPEREMIA. 4 1 

Secale Cor. Vertigo, headache, loss of consciousness, men- 
tal weakness, hammering and buzzing in the ears, obscuration 
of sight, paleness of the face, diarrhoea, metrorrhagia, spasms 
and convulsions. 

This remedy is particularly applicable to cases of cerebral 
anaemia caused by colliquative alvine evacuations, or by 
flooding. 

Veratrum alb. Headache aggravated by movement, espe- 
cially stooping, giddiness, vanishing of the senses, wakeful- 
ness, fainting fits, general coldness, violent vomiting and purg- 
ing, spasms and convulsions, followed or attended by paralytic 
weakness. 

This remedy is suited to similar conditions to those for 
which Secale cor. is indicated, but with this difference, that 
while the latter is better adapted to cases of cerebral anaemia 
depending upon uterine haemorrhage, Veratrum alb. is better 
suited to such cases as depend on losses occasioned by ex- 
cessive alvine discharges. 

For other remedies employed in this disease, consult Ta- 
bles V. and XII * 

Diet and Regimen. The diet, particularly in cases occa- 
sioned by loss of animal fluids, should be light and easily di- 
gestible, liberal in quantity, and nutritious. In most cases the 
moderate use of malt liquors may be allowed, but strong al- 
coholic drinks are unnecessary, and should be avoided. 

CEREBRAL HYPERJEMIA-CONGESTION OF THE BRAIN.f 

Hyperaemia of the the brain is either active or passive. 

Passive Hyperemia is the result of mechanical or other 
causes interfering with the return of blood from the brain, 
producing over-distension of its vessels, and consequent de- 
pression of its functions. 

Symptoms. Its characteristic symptoms are : coldness, es- 
pecially of the head, from enfeebled circulation, impeded res- 
piration, a sense of weight and fullness of the head, produc- 
ing more or less stupor or drowsiness, vertigo, impaired vision, 
lividity, or else undue paleness of the lips and face, nausea, 
and sometimes vomiting. 

* See American Horn. Observer, vol. vi., p. 556 ; vol. vii., p. 295. 
t See American Horn. Observer, vol. ii., p. 51. 
6 



42 THERAPEUTIC INDICATIONS. 

Treatment. The treatment of passive congestion consists 
in removing, as far as possible, the causes which produce it 
Rest, both physical and mental, and the avoidance of every- 
thing calculated to disturb the circulation, such as excess in 
eating and drinking, are of special importance in every case, 
and should be carefully observed. 

Active Hyperemia of the brain is more common than the 
variety just described, and is sometimes serious and even fa- 
tal; but it derives its chief importance from being the ordin- 
ary precursor of meningitis, hydrocephalus, and cerebral apo- 
plexy. It is generally characterized by one or more of the 
following 

SYMPTOMS. High excitement of the cerebral functions, 
vertigo, headache, delirium, morbid vigilance, or its opposite, 
stupor or drowsiness, confusion of mind, loss of memory, feel- 
ing of weight and fullness in the head, roaring and buzzing in 
the ears, confusion of sight, and other evidences of deranged 
vision, nausea and vomiting, and in some cases spasms and 
convulsions, or the opposite condition of muscular weakness 
and paralysis. 

ETIOLOGY. The chief predisposing causes of cerebral hy- 
peremia are : overrichness of the blood, or a plethoric condi- 
tion of the system,the sanguineous temperament, the cessation 
of growth, and the change of life. Among the more common 
exciting causes are : exposure to heat and cold, suppressed 
eruptions, rheumatism and gout, excess in eating and drink- 
ing, determination of blood to the brain, excessive mental la- 
bor, moral emotions, excitement of the passions, and mechan- 
ical injuries. 

Treatment. As in passive congestion of the brain,the first 
thing to be done is, as far as possible, to remove or lessen the 
exciting cause. This of itself will frequently produce entire re- 
lief. Hence, all excess in eating and drinking, the excitement 
of the passions, mental and bodily labor, and everything cal- 
culated to excite the circulation, or affect the mind, should be 
carefully avoided. 

THERAPEUTIC INDICATIONS. 

Aconite. Headache, with fullness and heaviness, as from a 
weight, throbbing and piercing pains in ^the head, forehead 
and temples ; heat and redness of the face and eyes, excess- 



CEREBRAL HYPEREMIA. 43 

ive photophobia, flashes of light, roaring in the ears, tempo- 
rary blindness, vertigo, aggravation of pains by movement, 
more or less relief in the open air. 

Aconite though generally inferior to Belladonna in cerebral 
hyperaemia, is perhaps the best remedy for that condition when 
caused by violent emotions, such as anger or fright. 

Arnica. Heat and burning in the head, with coldness of 
the body, throbbing headache in the forehead and temples, 
increased by warmth or exercise, nausea and vomiting, verti- 
go, delirium, loss of consciousness, tendency to apoplexy. 

Arnica is always the best remedy for congestion of the 
brain of a traumatic origin, or when produced by mechanical 
violence, such as falls, blows, etc. 

Belladonna* Sense of weight and heaviness in the head, 
with painful stitches, vertigo, delirium, loss of consciousness, 
redness of the face and eyes, roaring and humming in the 
ears, dilation or contraction of the pupils, morbid vigilance,or 
its opposite, stupor, great sensitiveness to light and noise, 
spasms and convulsions. 

This is by far the best general remedy for cerebral hyperae- 
mia, especially for children. 

Bryonia. Compressive pain in the head, especially in the 
morning, pain in both temples, pressing outwards, photopho- 
bia, buzzing in the ears, intolerance of light and noise, pain in 
the head increased or caused by stooping, bleeding of the 
nose, drowsiness during the day and disturbed and unrefresh- 
ing sleep at night, startings in sleep, with twitchings in the 
facial muscles, skin alternately hot and moist, nausea or vom- 
iting, constipation. 

This remedy is especially indicated when the above symp- 
toms are unrelieved by Aconite or Belladonna. 

Coffea cruda. Wakefulness at night; great nervousness and 
exaltation of the senses ; heat in the head and face, flushed 
face and cold feet; bleeding from the nose; buzzing in the ears; 
diarrhcea. 

Coffea is well suited to infantile cases of cerebral conges- 
tion, especially when caused by teething or diarrhcea. 

Gelseminum sempervirens. \ Headache,extending from occi- 
put to root of nose,dull,pressive and stupefying; vertigo; dim- 

* See Amer^Hom. Observer, vol. ii.Zp.143; also new series ,vol. i., p. 384. 
t See American Horn, Observer, vol. ii., p. 164.J 



44 THERAPEUTIC INDICATIONS. 

ness of vision; roaring in the ears; diplopia; amaurosis; sensi- 
tiveness to light; depression of spirits alternating with mirth- 
fulness; incoherency of thought, drowsiness, or its opposite, 
morbid vigilance. 

Gelseminum is an efficient remedy in cerebral congestion 
caused by teething, mental excitement, sunstroke and cata- 
menial suppression. 

Mercurius. Sensation of great pressure and fullness in the 
head, as though it would burst ; feeling as though the brain 
was compressed by an iron band ; great anguish and restless- 
ness, especially at night; pains in the head of a boring, tear- 
ing, shooting character ; lachrymation and burning of the 
eyes ; buzzing in the ears, with hardness of hearing ; vertigo. 

Mercurius is particularly applicable to rheumatic, arthritic 
and syphilitic cases. 

Nux Vomica. Cephalalgia, with nausea and vomiting; 
heaviness and confusion of the head ; soporose condition, with 
a tendency to apoplexy, or the opposite condition of wake- 
fulness ; burning of the eyes; intolerance of light, especially 
in the morning; altered vision; ringing and roaring in the ears; 
vertiginous intoxication and cloudiness. Symptoms aggra- 
vated by eating, exercising in the open air, and by coffee. 

Nux vomica is particularly suitable in such cerebral con- 
gestions as are caused by excessive mental labor, by the hab- 
itual use of intoxicating liquors, and by sedentary modes of 
life. 

Opium. Coma, with apoplectic symptoms ; stertorous 
breathing, confusion of the intellect, and sense of heaviness 
and pressure within the head, or the opposite condition of 
sleeplessness, with delirium, throbbing of the cerebral arte- 
ries, redness of the face, scintillations before the eyes, hum- 
ming in the ears, spasms, convulsions and paralysis. 

Opium is particularly indicated in those cases of cerebral 
hyperemia characterized by symptoms of depression, such as 
stupor, stertorous breathing, slow pulse, slow respiratory 
movement, and dark, livid redness of the face, with coldness 
and paleness of the rest of the body. It is also particularly 
useful in congestions caused by fright or debauchery. 

Pulsatilla. Drowsiness in the daytime, and sleeplessness 
and great restlessness at night; vertigo; confusion of the head; 



CEREBRAL HYPEREMIA. 45 

oppressive, beating headache; red, bloated face; fiery circles 
before the eyes; diplopia; buzzing in the ears; bitter, bilious 
taste in the mouth; nausea and vomiting. 

Pulsatilla is most suitable to cases of cerebral congestion 
occurring in young females, especially when caused by de- 
rangement of the catamenia, It is also well adapted to cases 
occasioned or aggravated by a disordered stomach, or by a bil- 
ious condition of the system. 

Rhus tox. Heavy, reeling headache; shaking or wavering 
sensation in the brain, especially when walking, vertigo when 
lying down; red and burning, or pale and puffy face; drowsi- 
ness in the daytime and restlessness at night. 

This remedy is applicable to such cases as arise from, or 
are associated with acute articular rheumatism, and also to 
cases caused by exposure to cold, or to getting wet and 
chilled. 

Veratrum viride. * Violent throbbing headache, heat and 
fullness in the head, with throbbing of the cerebral vessels, 
throbbing of the carotids, vertigo, flushed face, ringing in the 
ears, double vision, sensitiveness to light and sound, derange- 
ment of the stomach, palpitation of the heart, oppression of 
breathing, weakness and diminished sensation in the limbs, 
with spasms and tendency to paralysis. 

Veratrum vir. is one of the most powerful and efficient rem- 
edies for cerebral congestion, but nevertheless it requires to be 
used low to be effective. Its sphere of usefulness is similar to 
that of Belladonna. 

Diet and Regimen. The diet should be plain and unstim- 
ulating ; hence, every form of animal food, rich, or high-sea- 
soned dishes, coffee, and other stimulating drinks, should be 
carefully avoided. Moderation in eating and drinking, with 
regular habits, out-door exercise, bathing, early rising and 
cheerfulness, will facilitate recovery, and, so far as practica- 
ble, should be observed in all cases. 

For other remedies which may sometimes be found suita- 
ble, see the following table ; also consult the therapeutic indi- 
cations and tables under the head of Cephalalgia. 



* See American Horn. Observer, vol. vii., p. 55. 



46 



TABLE V. 



d s 

n d 
Eq Ph 



d .2 
o S 

I— I HH 



— r-i x 

-2 ^H M 



£ JS "S 



O r3 r-! 



a a 



a 


X 


o 


3 


ti 


S 










d 






d 


-d 


0) 

a 


3 



S <2 



« S5 




S ? £ £ 

- _, _ _ 



bo rt bo 

•S § .2 

H W H 




a a> 



d H » 



MS 



s s 



a a 



M Ph W « 



« « Pw Pm 



► 


O 


fs 


o 






e3 


^3 
O 


3 


32 


H 


CO 



P-l PL, 



2 2 2 S 



to to o 

a -2 s 

s I a 

S * 0) 

d m n 

PQ Pi P-. 



* g? 



Ph <J 



g? I 



to to 3 c° 

d S3 ^ 



to to £ 

G fl d 

>^ 3 2 to 



fl <l <) Pk « 



2 -& ft 2 *C 2 

□ T: -r-< r« t? "-• 



O fi 



o -g 

6 3 



P-. p-i 



2 © 

<J PQ 



PQ O 





3 

I 

a 

3 


52 

a 
id 




c3 




I 

X 

d 


a 

d 
ft 


g3 

1 

1 


02 

d 


c3 


■3 

cc 


1 


a 


ft 


O 


a 


H 


B 


o 


Ph 


Ph 


BQ 


> 



PRACTICE OF MEDICINE. 47 

VERTIGO-STUPOR-INSOMNIA. 

These morbid phenomena of the brain are frequently mere- 
ly isolated symptoms, depending upon cerebral conditions the 
pathology of which it is not always easy to settle, yet it is 
often of the greatest importance to do so. We shall endeavor 
in this article to point out the chief diagnostic signs by which 
the several conditions in question may generally be satisfac- 
torily determined. 

i. Vertigo, or giddiness, like cephalalgia, is generally 
symptomatic of some affection of the brain or its membranes, 
of which it is sometimes the chief indication ; at other times 
it is associated with disorder of the stomach, or with other 

Symptoms, of which the following are the most promi- 
nent : headache, more or less violent, in the temples and fore- 
head, aggravated by stooping, coughing, and mental exercise; 
buzzing or roaring in the ears, vanishing of the senses, op- 
pression of breathing, nausea, indigestion, constipation, pulsa- 
tion of the vessels of the head and neck, anxious expression 
of the countenance, which is pale and bloated or red and 
turgid, drowsiness during the day, and interrupted and unre- 
freshing sleep at night. 

DIAGNOSIS. Atlantic vertigo generally attacks the patient 
in the morning, is aggravated by exercise, especially in the 
open air, and is benefited by rest, particularly in the recum- 
bent position, and by food and stimulants. Hypercemic ver- 
tigo, on the other hand, seldom occurs in the morning, is of- 
ten ameliorated by persevering exercise and is increased by 
mental labor, stimulating food and drinks, and the recumbent 
position. 

Etiology. * The predisposing causes of anaemic vertigo 
are : mechanical obstructions, contraction or spasm of the 
cerebral vessels and organs, loss of animal fluids, etc. The 
chief predisposing cause of hyperaemic vertigo, on the con- 
trary, is a plethoric condition of the system, with a redun- 
dancy of blood in the cerebral vessels. The exciting causes 

* See American Horn. Observer, vol. viii., p. 284 et seq. 



48 STUPOR — INSOMNIA. 

are : over-indulgence in eating and drinking, the free use of 
spirituous and malt liquors, coffee, and other stimulating bev- 
erages, excessive mental exercise, grief, indulgence of the pas- 
sions, sedentary occupations, etc. 

Treatment. This, of course, should correspond with the 
pathological condition of the cerebral vessels, and is there- 
fore identical with that for Ancemia and Hypercemia of the 
Brain (which see); consult also Table XII., and the several 
diseases of which this is a characteristic symptom. 

DIET AND Regimen. In anaemic vertigo we should pre- 
scribe a nourishing diet, moderately stimulating drinks, and 
mental and bodily repose ; while in hyperaemic vertigo, the 
patient should rise early, take daily exercise in the open air, 
make free use of the flesh brush, observe regular habits, live 
sparingly, and carefully abstain from the use of every kind of 
stimulant. 

2. Stupor, or morbid drowsiness, is a condition of the 
brain which closely resembles natural sleep, but differs from 
it in being far less under the control of the patient's will. It 
is of every degree of intensity, from slight drowsiness to 
complete coma, in which consciousness is entirely lost. Press- 
ure upon the cerebral substance always produces it, and hence 
it is generally referred to that cause ; but careful investiga- 
tion shows that, like vertigo, it may depend upon exactly op- 
posite pathological conditions, being found associated with 
both depression and exaltation of the cerebral functions— 
that is to say, with both anaemia and hyperaemia of the brain 
and its membranes ; hence, the diagnosis, etiology and treat- 
ment of this condition are similar to those of the affection 
just described. 

3. Insomnia, or sleeplessness generally results from irrita- 
tion or over-excitement of the brain, and, as we have seen, is 
a prominent symptom of the hyperaemic condition of that 
organ. Certain stimulants, such as coffee and tea, exciting 
news, joy, hope, etc., are sufficient to produce it in some indi- 
viduals ; while the sudden withdrawal of alcoholic stimulants 
to which the patient has long been accustomed, furnishes a 



CEPHALALGIA— HEADACHE. 49 

striking example of its occasional dependence upon the op- 
posite condition of nervous and vascular depression. The 
same symptom is also frequently observed in cases of great 
general debility, where depression rather than exaltation of 
the cerebral functions is the apparent cause; Insomnia, there- 
fore, requires similar discrimination in treatment to that re- 
quired for vertigo and stupor ; indeed, there is in these affec- 
tions such a striking resemblance to each other in their path- 
logical conditions, as well as in their causes and associated 
symptoms, that notwithstanding the opposite character of the 
effects, the treatment required for each is similar and often 
identical. * See Cephalalgia, Cerebral A nccmia and Hypere- 
mia, and the corresponding tables. 

CEPHALALGIA-HEADACHE. 

Headaoh.9 is seldom an independent affection, but is gen- 
erally symptomatic of some other disease. Sometimes it de- 
pends upon derangement of the stomach, constituting what is 
called sick headache ; at others it is associated with hepatic 
disorder, constituting bilious headache ; and at others, it is 
symptomatic of some intestinal, renal, uterine, cerebral or 
spinal affection. The most opposite conditions of the circu- 
lation produce it, such as active and passive congestion, ana> 
mia,or plethora. So, also, it may depend upon nervous irrita- 
tion, or nervous depression. Sudden cold, suppressed erup- 
tions, severe mental labor, excess in eating and drinking, 
rheumatism and gout, determination of blood to the head, 
and external injuries, are among the more common causes of 
the affection, and require to be considered in the treatment. 
Errors of diet, also, frequently produce it, as well as the vari- 
ous mental emotions, such as anger, grief, fright, anxiety, 
chagrin, and even joy itself. There are also nervous and hys- 
teric headaches, which are frequently symptomatic of uterine 
derangement'; but these are sometimes dependent only upon 
functional disorder of the nervous system. 

Treatment. Most headaches may be readily cured by 
the removal of the cause, and by quietude. Thus, if caused 

* See American Horn. Observer, vol. iii., p. 474. 
7 



50 THERAPEUTIC INDICATIONS. 

by watching or by mental labor, simple rest is all that is re- 
quired. If caused by a derangement of the stomach, absti- 
nence from food for a short period will relieve it. So, also, if 
coffee, beer, wine, or other drink, is the exciting cause, of 
course it should be laid aside, or medicine will do but little 
good. 

THERAPEUTIC INDICATIONS.* 

Aconite. Compressive and stupefying pains, with a sensa- 
tion of fullness and heaviness in the head ; throbbing and 
piercing pains in the forehead and temples, congestive head- 
ache, with heat and redness of the face, ringing in the ears, 
and redness, smarting or burning of the eyes ; vertigo, with 
nausea, especially when stooping, suddenly rising, or moving 
the head; determination of blood to the head, with throbbing 
of the vessels of the neck, rapid pulse, and burning heat of 
the face and scalp. Aggravation of the pains from move- 
ment ; amelioration in the open air. 

Aconite is a useful remedy for catarrhal, rheumatic and 
nervous headaches, also for those arising from determination 
of blood to the head. {Cerebral Congestion) 

Belladonna. Intense pain in the forehead ; feeling of full- 
ness and pressure in the head, as though it would burst; vio- 
lent throbbing and sensation of fluctuation within the head, 
lacerating pains over the eyebrows; undulating shocks, extend- 
ing from before backwards, and to either side; heaviness of 
the head, producing a feeling of intoxication ; rush of blood 
to the head, with beating of the carotids, redness of the eyes, 
and buzzing in the ears; excessive sensibility to light and noise 
or clouded vision, with vertigo. {Congestive Headache) Ag- 
gravation of the symptoms by stooping ; partial relief by ly- 
ing down. 

Belladonna is particularly applicable to cases of congestive, 
catarrhal and arthritic headaches, especially when occurring 
in females, and persons of highly sensitive organizations. 

Bryonia. Burning, beating headache, especially in the 
morning and after meals; rush of blood to the head, with feel- 

* See American Horn. Observer, vol. viii., p. 33, et seq. 



PRACTICE OF MEDICINE. 51 

ing of compression, darting pains in the head, especially on 
one side ; jerking, shooting and drawing pains through the 
head, sometimes with nausea or vomiting ; pain in both tem- 
ples, with pressure from within outwards ; heat and congestion 
in the head; with soreness of the scalp, aggravation by move- 
ment. 

Bryonia is most useful in those cases in which constipation 
is the principal cause of the headache. 

Calcarea carb. Semi-lateral headache, with nausea and 
eructations ; throbbing, beating, or pressing pains in one side 
of the head, or in the forehead ; drawing, cramp-like pain in 
the top of the head, with coldness of the forehead, headache 
every morning ; aggravation by study, spirits, exercise, and 
mental emotion. 

Especially suited to scrofulous subjects. 

Chamomilla. Oppressive, drawing headache in one side, 
with redness of one cheek and paleness of the other ; dull, 
heavy, throbbing headache, with hot perspiration of the scalp; 
nervous and hysteric headaches ; also, headaches caused by 
cold, or associated with catarrhal affections. 

Especially adapted to irritable children. 

China. Lacerating, darting, cutting, hammering, conges- 
tive headaches, especially when caused by debility, or by loss 
of fluids; hemicrania, with soreness of the scalp; aggravated 
by drafts of air, movement, or contact. 

Cimicifuga. Throbbing and pressing pains in all parts of 
the head, especially the occiput and vertex, and generally as- 
sociated with pain in the back and along the spine ; feeling of 
extreme fullness within the cranium, as though the skull would 
burst. 

Adapted to weak, nervous, hysterical females, especially 
when the catamenia are deranged ; also, to headaches caused 
by a debauch, or by excessive study. 

Glonoine. * Throbbing headache in the forehead, vertex and 
occiput; stitching pains in the temples, headaches arising from 
suppression of the menses, from exposure to the sun, or from 
rush of blood to the head, especially when characterized by 
redness of the face and eyes. 

* See American Horn. Observer, vol. x. ; p. 477. 



$2 THERAPEUTIC INDICATIONS. 

Ignatia. Paroxysmal headache of a congestive character; 
beating, hammering, or pulsating headache, attended by nau- 
sea, obscurity of vision, photophobia, or frequent micturition; 
also, by soreness of the scalp and clavus. Pains are aggrava- 
ted by coffee, wine, tobacco, noise, or mental emotion. 

Ignatia is particularly suitable for pale, irritable, hysterical 
females,especially in cases of hemicraniaor megrim; also,when 
the pain is limited to a particular spot, with the sensation as of 
a nail driven into the head. (Clavus) 

Ipecacuanha. Headache with nausea, or sick headache; lac- 
erating pain in the forehead, attended by nausea or vomiting; 
tensive, aching pains extending as far as the neck and shoul- 
ders ; sensation of soreness in the whole brain. 

Suitable after or in alternation with Nux vom. y especially af- 
ter a debauch. 

Mercurius. Tearing, shooting, boring pains in the head, 
particularly on one side; digging, aching pains in the bones of 
the skull ; syphilitic headache; heat and burning in the head, 
rheumatic headache ; shooting pains in the ears, neck and 
teeth; nightly perspirations which afford no relief; aggravation 
of the pains at night or when warm in bed. 

This remedy is especially indicated in syphilitic cases, or 
when associated with eruptions on the scalp, falling off of the 
hair, or cranial exostosis. 

Nux vom. Congestive headache, with sensation as of a 
nail driven into the head; lacerating pain in the forehead; 
headache with nausea and vomiting, hemicrania ; headache 
from watching, excessive mental exertion, and the abuse of 
coffee or spirituous li4uors ; also, catarrhal and rheumatic 
headaches. 

Especially adapted to violent, irascible dispositions, and 
particularly after a debauch or when attended by constipa- 
tion. 

Pulsatilla. Headache from indigestion, or from eating fat 
meat ; headache attended with nausea from the presence of 
bile in the stomach ; beating headache, with vomiting of bile 
and mucus ; hemicrania, with shooting pains extending into 
the ears and teeth ; lacerating, sticking pains in one side of 
the head. Aggravation in the evening and when at rest ; — 
amelioration by compression, and in the open air. 



THERAPEUTIC INDICATIONS. 53 

Suitable to females of mild disposition, especially when the 
menses are scanty or deranged. 

Sangninaria. Periodical sick headache, characterized by 
daily, weekly, or monthly paroxysms, beginning in the morn- 
ing, increasing during the day, and subsiding at night, and ac- 
companied with more or less nausea and vomiting. The pains 
are commonly sudden, sharp and severe, like electric strokes, 
and affect every part of the head, especially the forehead and 
occiput. Piercing, digging, lancinating pains, most severe on 
the right side, accompanied by chilliness, nausea, bilious 
vomiting, and great sensitiveness to noise, light, touch and 
motion. 

Sepia. Paroxysmal hemicrania, occurring in violent shocks, 
especially when connected with affections of the reproductive 
system ; throbbing, beating, tearing headache, frequently ac- 
companied by more or less heat, photophopia, nausea and 
vomiting ; headache caused by indigestion, especially in deli- 
cate females, or when associated with amenorrhcea, chlorosis, 
leucorrhcea, and other uterine derangements. 

Stramonium. Spasmodic, beating headache, with obscura- 
tion of sight and dullness of hearing ; hammering in the ver- 
tex ; giddiness, with thirst, and disposition to faint ; conges- 
tive headache, with swelling and redness of the face and eyes. 

Sulphur. Congestive headache, with throbbing and heat ; 
pressure from within outwards, as though the head would 
burst, especially in the forehead ; jerking, shooting, or draw- 
ing pains in one side of the head ; obscuration of sight ; par- 
oxysms attended with nausea and vomiting. Aggravation by 
thinking, the open air, and by movement. 

Especially suited to cases caused by suppression of erup- 
tions. 

REMARKS. 

Calcarea, China, Sepia, and Sulphur, are especially adapted 
to chronic cases, particularly when associated with some vice 
of constitution, or derangement of the organs of digestion 
and assimilation. Calcarea and Sulphur, particularly, are of- 
ten indispensably necessary to effect a permanent cure, es- 
pecially in very old, obstinate, and intractable cases. For 
further information consult the following tables. See also, 
Table V. 



54 



TABLE VI. 



•Toy. Grief. ITrigh.t. Chagrin. Anger. 


w 
K 

o 

1 

> 
r 1 


' CHAMOMILL. 
IGNATIA 
Aconite 

Belladonna 
Nux vomica 

' CHAMOMILL. 
Lycopod. 

Sepia 

Nux vomica 

Staphysagria 

' OPIUM 
Aconite 
Hyoscyamus 
Spigelia 

' IGNATIA 
Phosphor, ac. 
Natr. mur. 
Staphysagria 

' COFFEA 
Opium 
Crocus 
Natr. carb. 


ACONITE 

BELLADONN. 

BRYONIA 

CHINA 
LACHESIS 
MERCURIUS 
NIT. AC. 
NUX VOMICA 
SULPHUR 

Alumina 

Ambra 

Ant. 

Arnica 

Aurum 

Calc. o. 

Cannabis 

Dulcamara 

Gelseminum 

Glonoine 

Ignatia 

Iodium 

Kali 

Lycopod. 

Manganese 

Moschus 

Nux vomica 

Opium 

Phosphorus 

Pulsatilla 

Chamomilla 

Coffea 

Colocynth 

Rhus 

Silicea 

Spongia 

Veratrum vir. 


Q 

o 

c 
w 

m 

< 


NERVOUS. 

ACONITE 
BELLADONN. 
NUX VOMICA 

Chamomilla 

Gelseminum 

Hepar. 

Sepr. 

Valeriana 

Arnica 

Arsenicum 

Aurum 

Bryonia 

Calcarea 

Capsicum 

Cimicifuga 

Colocynthis 

Cicc. 

Coffea 

China 

Cypr. 

Glonoine 

Ignatia 

Ipecacuanha 

Petroleum 

Platina 

Pulsatilla 

Rhus 

Silicea 

Spigelia 


HYSTERICAL. 

CIMICIFUGA 
CHAMOMILL. 
MOSCHUS 
VALERIANA 

Arsenicum 

Aurum 

Caul. 

Cocculus 

Gelseminum 

Ignatia 

Lachesis 

Magn. 

Magn. m. 

Nit. ac. 

Phosphorus 

Platina 

Sepia 

Capsicum 
Rhus 
Spigelia 
Veratrum 


RHEUMATIC. 

ACONITE 

ARSENICUM 

BRYONIA 

CAUSTICUM 

COLCHIUM 

LYCOPOD. 

MERCUR. 

NUX VOMICA 

PULSATILLA 

RHUS 

Belladonna 

Cimicifuga 

Lachesis 

Ledum 

Sepia 

SuLrnuR. 

Arnica 
Chamomilla 
China 
Ignatia 
Magn. m. 
Nitr. ac. 
Phosphorus 
Spigelia 


ARSENICUM 

BELLADONN. 

BRYONIA 

CAUSTICUM 

CALC. C. 

PULSATILLA 

Aconite 

Arnica 

Colocynth. 

Ignatia 

Kali bic. 

Sabina 

Sepia 

Sulphur. 

Aurum 

Capsicum 

Cicuta 

Ipecacuanha 

Manganese 

Nit. ac. 

Petroleum 

Phosphor. 

Veratrum 

Zincum 


> 

% 

B 
W 

s 


CATARRHAL 

ACONITE 
BRYONIA 
NUX VOM. 
PHOSPH. 

PULSAT. 

Belladon. 

Chamomil. 

Mercur. 

Sticta 

Sulphur. 

Arnica 

Arsenicum 

Carb. v. 

China 

Cin. 

Cimicifuga 

Dulcamara 

Ignatia 

Lachesis 

Kali 

Lycopod. 


!!!!!!! III? 1^ g|3g 


> 

2 
p 


BELLAD. 

CIMICIF. 

NUX VOM. 

PULSAT. 

Aconite 

Arsenicum 

Caul. 

Ignatia 

Lachesis 

Platina 

Sepia 

Bryonia 

Calcarea 

China 

Cocculus 

Colocynth. 

Dulcamara 

Ferrum 

Kali bic. 

Magn. 

Nat. m. 

Spigelia 

Veratrum 


w 
3 
a 

H 


ACONITE 
BELLAD. 
ARNICA 

Arsenicum 
Calcarea 
Conium 
Mercur. 

Cicuta 
Hepar. 
Petroleum 
Rhus 
Sulphur ac. 


►3 

d 
> 

p 



H 
in 

n 

> 

X 

H 



TABLE VII. 



55 



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56 DISEASES OF THE ENCEPHALON. 

MENINGITIS. 

INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. 

Meningitis is a term which strictly speaking, signifies in- 
flammation of the membranes of the brain ; but as it is gen- 
erally used to denote inflammation of both the brain and its 
membranes, and as inflammation of the cerebral membranes 
seldom exist without involving, to a greater or less extent, 
the substance of the brain itself; and since there are no char- 
acteristic symptoms that can be relied upon to distinguish 
them from each other, we shall apply the term indiscrimin- 
ately to both ; or rather we shall use it in its ordinary sense, 
to denote that exceedingly dangerous disease known as in- 
flammation of the brain. There is a form of it sometimes call- 
ed tubercular or granular meningitis, depending on the pres- 
ence of tuberculous deposits in the membranes of the brain, 
which being a separate affection we shall treat of under a dif- 
ferent head. 

SYMPTOMS. Inflammation of the brain is divided into two 
well defined periods, or stages, the disease being generally, 
but not always, preceded by certain premonitory symptoms, 
such as vertigo, insomnia, ringing in the cars, loss of appetite, 
and general uneasiness. 

First Stage. The first stage begins with the usual symp- 
toms of fever — such as chilliness, succeeded by heat, acceler- 
tion of the pulse, thirst, etc. To these are added, flushing of 
the face, intense headache, a wild, staring expression of the 
eyes^ vertigo, intolerance of light and sound, suffusion of the 
eyes, ringing in the ears, restlessness, anxiety wakefulness, 
delirium, spasmodic movements, contracted pupils, hot but 
sometimes moist skin, nausea and vomiting. The fever that 
characterizes it is of a high inflammatory type, attended by 
a full, hard, and bounding pulse ; throbbing of the temporal 
arteries, rapid and irregular breathing, throbbing, stabbing, 
and cutting pains in the head and extremities, rolling of the 
eyes, excessive thirst, scanty and high colored urine, and con- 
stipation. 



MENINGITIS. 57 

Second stage. After the lapse of twelve, twenty-four, or 
forty-eight hours, and sometimes a week or more, according to 
the violence of the disease, the second period ^r stage of col- 
lapse sets in. The headache now subsides, the delirium passes 
gradually into stupor or coma, the pupils become dilated, the 
eyes dim and sunk in their sockets, the hearing greatly im- 
paired, the pulse small, rapid and intermittent, and the skin 
cold and clammy ; the convulsions subside into muscular re- 
laxation or paralysis, and a general state of insensibility suc- 
ceeds, which soon terminates in death. 

Modifications. The symptoms are of course variously 
modified according to the extent and violence of the dis- 
ease, the age of tbe patient, and the nature of the exciting 
cause. Sometimes the disease begins and ends with convul- 
sions — at other times, pain in the head, delirium or coma, 
may constitute the principal symptom. Indeed, no disease 
presents itself under a greater variety of forms, or with a 
greater diversity of symptoms ; the latter, however, are gen- 
erally present in sufficient number, and are sufficiently char- 
acteristic, to make any mistake in the diagnosis both un- 
necessary and inexcusable. 

Etiology. Among the exciting causes of this disease, 
may be mentioned: external violence, teething, the suppres- 
sion of cutaneous eruptions, the translation of rheumatism 
or gout, venereal excesses, abuse of liquor, mental emotions, 
and certain fevers — such as typhoid fever, scarlet fever, and 
erysipelas. 

TREATMENT. The treatment of Meningitis is similar, and 
in most cases identical with that of Hyperaemia of the Brain. 
In addition, therefore, to the Therapeutic Indications con- 
tained in the following Table (VIII), the practitioner should 
consult the Indications and Tables given under the head of 
Cerebral Hyperaemia. 

DIET AND Regimen. For the first few days the diet 
should be restricted to such simple articles as toast water, 
gum-water, barley or rice-water, jellies, etc.; and until the 
stage of excitement is fully past, should be of the mildest 
and most unstimulating character. The room should be kept 
cool, quiet and well ventilated, and the patient as compos- 
ed as possible. 



58 



TABLE VIII. 



OD 

M 

< 

H 

S3 


Vomiting of bile; espe- 
cially indicated at the 
commencement. 

Especially suited to the 
last stage. 

Emesis. Relaxation of 
sphincters. 

Working of the jaws. 
Opisthotonos. 

Last stage, or when 
caused by the reper- 
cussion of erysipelas. 

Especially indicated aft- 
er retrocession of vesi- 
cular erysipelas. 

When caused by worms, 
or pseudo-meningitis. 


'72 

>— 1 


Burning, throb- 
bing or lanci- 
nating. 

Throbbing, sting- 
ing and lacer- 
ating. 

Boring, stinging, 
burning, lanci- 
nating or throb- 
bing. 

Sharp and violent, 
or pressive and 
aching. 

Lacerating and 
cramp-like. 

Pressing, gnawing, 
throbbing, or 
lancinating. 

Cramp-like. 


-A 
H 

>< 


Red and inflamed 
Pupils contract- 
ed or dilated. 

Burning, stinging 
and staring ; 
dimness of vis ; 
pupils contract- 
ed. 
Red and sparkling, 
with distorted 
orbs; pupils con- 
tr'ted or dilated. 

Red and inflamed ; 
sparkling, or dim 
and glassy. 

Staring and in- 
flamed; pupils 
contracted. 

Fiery and spark- 
ling, protruded 
and distorted; 
dimness of vis'n. 

Pupils dilated or 
contracted; dim- 
ness of vision. 




Full and hard. 

Rapid, feeble and 
intermittent. 

Small, quick and 
intermittent. 

Quick and hard, 
or slow and in- 
termittent. 

Full and quick, or 
small and hard. 

Full and hard. 

Generally quick 
and irritable— 
sometimes 
trembling. 


SKIN. 

Dry burning heat, 
Erysipelas. 

Burning and 
Swollen— with 
or without 
Moisture. 

Red and burning 
—Erysipelas. 

Hot and burning, 
sometimes cold, 
pale and moist. 

Blue or pale, Ery- 
sipelas. 

Red and burning, 
Vasicular Ery- 
sipelas. 

Burning Heat, 
especially of 
the face. 


CO 

•A 
U 


Spasms, or Ten- 
dency to Para- 
lysis. 

Spasms- Paraly- 
sis. 

Spasms -Paraly- 
sis. 

Cramps, Convul- 
sive Movem'nts. 

Cramps and Con- 
vulsions. 

Tonic Spasms and 
Convulsions. 

Cramps and Con- 
vulsions. 


o 

CG 


Delirium, with 
great anguish. 

Delirium, Giddi- 
ness or Insen- 
sibility. 

Violent Delirium 
— Loss of Con- 
sciousness. 

Vertigo, Delirium 
or Sopor. 

Vertigo, Loss of 
Consciousness. 

Delirium, Vertigo, 
or Insensibility. 

Violent Headache 
Giddiness, and 
Delirium 


REMEDY. 


— 

c 

< 


ARSENICUM 

BELLADONNA.... 
BRYONIA 


C 

< 


m 
H 
Q 

< 
» 





TABLE VIII — CONTINUED. 



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60 Diseases of the encephalon. 

CEREBRITIS-ENCEPHALITIS. 

INFLAMMATION OF THE SUBSTANCE OF THE BRAIN. 

Cerebritis and Encephalitis are terms commonly used to de- 
note partial inflammation of the substance of the brain, in 
contradistinction to general inflammation of that organ, which 
seldom or never occurs without involving the cerebral mem- 
branes, particularly the pia mater and arachnoid coats, and 
is therefore described under the head of Meningitis. 

This disease is not only confined to a limited portion of the 
cerebral substance, but it is also generally of a more or less 
chronic character. It is, however, sometimes acute, particu- 
larly if the inflammation involves a considerable portion of 
the cerebral mass, in which case the inflammation passes rap- 
idly through its several stages, and may soon terminate in co- 
ma, convulsions, paralysis, or death. Even when the inflam- 
matory process is limited to a very small portion of the brain, 
it may prove speedily fatal, in consequence of the particular 
part affected; as, for example, the corpora pyramidalia of the 
medulla oblongata, or the part contiguous to the pia mater 
and arachnoid membranes. 

Pathology. Inflammation of the substance of the brain 
generally begins with exudation between the fibres situated 
along the boundary separating the cineritious and white sub- 
stance. Sooner or later, owing to the vascular structure and 
highly organized nature of the organ, the exudation results in 
disorganization of the cerebral textures, producing at first 
what is called red softening from the presence of blood in the 
broken down tissues, which gradually changes to yellow soften- 
ing by reabsorbtion of the coloring matter of the exudation. 
Sometimes, for reasons difficult to explain, the exudation 
changes to pus, into which also, the implicated tissues are 
converted, forming cavities or abscesses in the brain, which vary 
greatly both in size and number. These abscesses generally 
result from injury of the cerebral substance, but do not always 
correspond to the seat of injury. They are subject to a variety 
of terminations. Sometimes they become enclosed in cysts of 
false membrane, which, by limiting the extent of the inflam- 
matory process, prevent any further disorganization of the 



GEREBRITIS — ENCEPHALITIS. 6l 

cerebral texture ; at other times they make their way into the 
ventricles, or to the surface of the brain, producing inflam- 
mation of the investing membranes, and death. 

Abscesses of the brain, however, do not always terminate 
in death, as cases sometimes occur in which there is every 
reason to conclude that the purulent matter has been absorb- 
ed ; cicatrices having been found in the brains of old people, 
which could only be accounted for in this manner. 

Among the various pathological states incident to this dis- 
ease is that of ulceration, which, however, is of comparatively 
rare occurrence. The ulcers, which vary in size from a few 
lines to several inches, are situated, for the most part, on the 
external surface of the brain, seldom penetrating beyond the 
grey substance. The tissues immediately surrounding the 
ulcers, as well as the adjacent membranes, usually exhibit 
signs of inflammation ; and occasionally they are found to 
communicate with deep-seated abscesses. 

Encephalitis of a very chronic character, instead of produc- 
ing softening or ulceration of the cerebral substance, sometimes 
gives rise to a state of permanent i?idnration of the part af- 
fected. The old writers relate many such cases of partial in- 
duration, all of which were of a very protracted nature. In 
some cases the affected parts were unusually red and vascular; 
in others, they were of a pearly whiteness, and of different de- 
grees of density, from that of semi-concrete lymph to that of 
fibro-cartilage. 

SYMPTOMS. The various pathological conditions above de- 
scribed, prepare us to expect a great diversity of symptoms 
in different cases; they are likewise found to be extremely 
vague and unreliable. We have already stated that the dis- 
ease may assume more or less of an acute character from the 
beginning, especially when large portions of the brain are im- 
plicated. In such cases the disease generally involves the me- 
ninges of the brain, and runs a rapid course. In other cases, 
comparatively large portions of the cerebral tissue may be 
affected without its functions being proportionately, or to any 
great degree, disturbed. Even when the initial symptoms are 
most complete, they are not always sufficiently pronounced to 



62 CEREBRITIS — ENCEPHALITIS. 

enable us, at the outset of the disease, to distinguish it with 
any degree of certainty from other inflammatory affections of 
the brain. 

First stage. The patient is generally attacked with severe 
deep-seated pain in the head, commonly of a continuous, but 
sometimes of a paroxysmal character, which frequently pre- 
cedes all other symptoms. Afterwards, and sometimes from 
the very commencement, other symptoms are experienced, 
such as vertigo, dimness of vision, buzzing in the ears, dispo- 
sition to faint, nausea and loss of appetite, hesitancy of 
speech, wandering pains in the limbs, sensation of numbness 
or tingling in various parts of the body, with heaviness 
and cramps in the extremities, and an unsteadiness of gait, 
betokening the approach of paralysis. This constitutes the 
first stage, beyond which there is but little, if any hope of 
recovery. 

Second stage. Although the general health is now more or 
or less impaired, the ordinary absence of fever, and of any 
derangement of the intellect, prevents, as a general rule, ap- 
prehensions of impending danger, until at last the patient is 
suddenly seized with stupor, insensibility, and paralysis. — 
From this condition the patient may so far recover as to ex- 
hibit some signs of intelligence, but some degree of drowsi- 
ness, apathy and mental weakness, as well as loss or impair- 
ment of the special senses, remains. This is called the second 
stage ; and is characterized at its close by rigid contractions of 
the flexor muscles of the paralyzed limbs. This condition of 
rigidity, or tonic spasm, is supposed to indicate the process of 
softening of the cerebral tissues. 

Third stage. If the patient survive the second stage of 
the disease, the rigidity of the paralyzed muscles gradually 
gives way, and is succeeded by the opposite condition of re- 
laxation and flaccidity. This marks the third stage, or that 
of complete paralysis, in which the affected portion of the 
brain has become wholly disorganized and broken down. The 
patient now, either suddenly or gradually, sinks into a state of 
profound coma, from which the system never rallies, and 
death sooner or later closes the scene. 



CEREBRITIS — ENCEPHALITIS. 63 

The above is a very imperfect sketch of the history and' 
progress of this disease, which is marked at different stages 
with more or less irregularity of function, fever, delirium, and 
spasmodic action ; giving rise to a diversity and succes- 
sion of symptoms in different cases, which constitute certain 
forms and varieties of cerebritis, that our limited space forbids 
us to describe. This, however, is quite unnecessary, since the 
description already given is sufficiently characteristic to ena- 
ble the practitioner always to identify the disease with the aid 
of the following 

DIAGNOSIS. Cerebritis is liable to be mistaken in the first 
stage for meningitis, and in the succeeding stages for apo- 
plexy. In cerebral meningitis the febrile excitement is very 
great, and is attended with spasmodic and convulsive symp- 
toms on both sides of the body, and without decided paraly- 
sis, succeeded by collapse. In cerebral apoplexy, on the 
other hand, there is generally a more sudden invasion and 
rapid progress of the disease, together with sudden and 
complete paralysis, unattended at first with spasmodic 
symptoms. 

With reference to convulsions, coma and paralysis, it should 
be remembered, that partial congestion from moderate com- 
pression will produce convulsions; while increased congestion 
from a greater degree of compression, will produce coma and 
partial paralysis ; hence the results of cerebral congestion 
alone are sometimes similar to those of cerebral inflamma- 
tion. The diagnosis, therefore, should embrace other symp- 
toms than those of convulsions, coma, and paralysis, such as 
delirium, altered pulse, altered pupils, etc. This hint will be 
sufficient in most cases to prevent any serious mistake in di- 
agnosis, even when the symptoms are more than usually di- 
verse and obscure. 

ETIOLOGY. As already stated, partial inflammation of the 
cerebral substance is frequently the result of traumatic inju- 
ries, such as blows, falls, etc. It is also caused by the growth 
of foreign bodies in the brain ; such as hydatids, fibrous, fibro- 
cartilaginous, and carcinomatous tumors, and the effusion of 
sanguinous, tuberculous and scrofulous collections. But the 
most common causes are doubtless the same as those of sim- 
ple meningitis ; of these, the depressing passions, long con- 
tinued and severe mental labor, and habitual drunkenness, are 
perhaps the most constant and powerful. 



64 CEREBRITIS— EN CEPHALITIS. 

TREATMENT. The treatment of cerebritis in the first stage 
or what is sometimes called irritative cerebritis, should be 
similar to that recommended for Cerebral Hyperaemia and 
Meningitis. So long as no insterstitial change has taken place 
— no metamorphosis of structure — we may reasonably hope 
to relieve the symptoms, which are simply those of congestion 
and inflammation. But when softening has once set in, with 
its formidable train of effects, the reactive powers of the sys- 
tem are either wholly lost, or too much injured and enfeebled 
to render any hope of permanent relief. Something, howev- 
er, is always expected to be done ; and the indications being 
similar to those mentioned under the head of Cerebral Apo- 
plexy, the prescriber is referred to that section. Additional 
therapeutic indications and remedies may also be found under 
the heads of Acute Hydrocephalus and Cerebral Concussion, 
the symptoms of which frequently correspond to those of cer- 
tain forms and stages of chronic encephalitis, and therefore 
require the same remedies. 

We will add, on the authority of Hempel, that Kafka has 
for some years been in the habit of employing Glonoine ist to 
2d, with the best success in encephalitis, " When the symp- 
toms of cerebral hyperaemia predominate, and the disorganiz- 
ing metamorphosis is progressing!' 

We beg leave to take exception to the condition mentioned 
in the last clause as existing in the cases, though we have no 
doubt whatever that Glonoine will prove a valuable remedy 
in the initial and purely hyperaemic stage of the complaint. 

Kafka also relates a case in which, " Side by side with the 
symptoms of cerebral hyperaemia, those- of cerebral softening, 
with progressive increase of the morbid phenomejia, likewise co- 
existed; and in which, after the hyperaemic condition had been 
relieved by the employment of Glonoine and Belladonna. — 
Arsenicum was used apparently with marked success. If 
it be possible for entire recovery to take place in this disease 
after metamorphosis of the cerebral tissue has occurred, I have 
no doubt Arsenicum will prove an efficient remedy, not only 
because it is capable of producing decomposition of organic 



ACUTE HYDROCEPHALUS. 65 

tissues, but because its pathogenesis as exhibited in the cepha-. 
lalgia, vertigo, wandering pains, impaired sensibility of the 
limbs, delirium, coma, lassitude, debility, trembling, and 
numbness of the extremities, and the tetanic spasms, or pa- 
ralysis, presents a perfect picture of cerebritis, and must, 
therefore, be truly homoeopathic to that condition. 

Iodium is another medicine which seems to have yielded 
good results in some cases, and so far as the pathogenesis of 
the remedy is concerned, is certainly appropriate, but we are 
obliged to confess that our experience with it in this class of 
cases has not been satisfactory. 

Plumbum, also, has been strongly recommended in cere- 
britis, but so far, we believe, only on theoretical grounds. 



ACUTE HYDROCEPHALUS. 

TUBERCULOUS OR GRANULAR MENINGITIS. 

If the term used to designate simple inflammation of the 
brain is etymologically inapposite, much more so is that which 
is generally employed to distinguish scrofulous inflammation 
of that organ, namely, hydrocephalus, or dropsy of the brain, 
a condition belonging only to the chronic variety, since the 
limited effusion of serum into the ventricles, which occurs in 
some cases of this disease, is nothing like true dropsy, in 
the sense in which that term is usually understood ; but as 
homceopathists both recognise and treat diseases by symptoms 
instead of names, the inaccuracy of the allopathic nomencla- 
ture is of but little consequence. 

PATHOLOGY. Acute hydrocephalus is essentially a scrofu- 
lous inflammation of the brain ; at least, it is generally, if not 
universally, associated with a scrofulous or tuberculous con- 
dition of the system; indeed, the disease is chiefly characterized 
by deposits of scrofulous matter, in the form of millet-sized 
tubercles, or granules, in the meninges of the brain ; hence it 



66 PRACTICE OF MEDICINE. 

is sometimes called granular or tuberculous meningitis* The 
granulations are of a greyish or yellowish-white color, similar 
both in character and appearance to those which sometimes 
occur in ordinary miliary tuberculosis in other organs. They 
are located for the most part in the pia mater at the base of 
the brain. It is only in a small proportion of cases that they 
occur elsewhere. This, however, it should be stated, is con- 
trary to the original observations of Rilliet and Barthez, who 
found them to occur most frequently upon the convex surface 
of the brain. The truth is, they are situated mainly along the 
course of the great vessels, particularly in the fissure of Silvius. 
In some instances they are so closely aggregated as to coalesce, 
forming tuberculous masses of the size of a pea or bean. There 
is also to be found in the sub-arachnoidal space, adjoining the 
blood vessels, a jelly-like exudation similar to what occurs in 
simple meningitis. There is generally much softening of the 
cerebral tissue around the ventricles, owing probably to the 
effusion into them of a greater or less quantity of serum. As 
already stated, miliary granules, tubercles, and other evidences 
of scrofulosis, are generally found in other portions of the body, 
particularly in the lungs, bronchial glands and peritoneum, 
proving conclusively that acute hydrocephalus is nothing more 
nor less than a true scrofulous inflammation of the brain, — a 
fact the knowledge of which is of the greatest consequence so 
far as prognosis and treatment are concerned. 

SYMPTOMS. Acute hydrocephalus may occur at any period 
of life, but is almost wholly confined to infancy and childhood. 
Its course exhibits four different stages, or periods, the charac- 
teristic symptoms of which are so different, that, for the purpose 
of comparison, we present them in tabular form. (See pp. 68, 
69.) 

Etiology and Prognosis. Acute hydrocephalus is so 
exceedingly fatal, in consequence of the scrofulous diathesis of 

* See Am. Horn, 05s., vol. 7, p. 58. 



ACUTE HYDROCEPHALUS. 6j 

the patient, and the presence of tuberculous matter in the 
cerebral meninges, that the only chance for successful treat- 
ment lies in its early recognition.* Hence it is of the utmost 
importance that proper treatment be instituted during the pre- 
monitory or congestive stage, as then the symptoms will gener- 
ally be found to yield. At the same time we would caution 
the practitioner always to be on his guard, since, in consequence 
of the strong predisposition existing in these cases, and the 
irritation caused by the presence of foreign matter within the 
cranium, there will be a constant tendency to relapse upon ex- 
posure to any exciting cause, such as falls, blows, exposure to 
cold or heat, the irritation produced by worms or teething, 
rapid jolting or exercise, the repercussion of cutaneous erup- 
tions, ordinary attacks of fever and inflammation, or indeed 
anything calculated to quicken the circulation and cause a de- 
termination of blood to the brain. Hence the greatest care 
should be taken in such cases to keep the child quiet ; to guard 
against external violence or undue excitement of any kind ; to 

promote the general health by gentle passive exercise ; and to 
regulate the motions of the bowels and the functional activity 
of the skin by diet, bathing, friction, etc., with the greatest 
care. 

DIAGNOSIS. The disease with which acute hydrocephalus 
is most apt to be confounded is simple meningitis, which some- 
times bears so close a resemblance to this affection as to render 
it extremely difficult to distinguish it from the scrofulous va- 
riety. Doubtless the most certain diagnostic sign is the co- 
existence of a general scrofulous condition of the system. If 
there should be no external marks of scrofula, no hereditary 
taint, nor any signs of disease within the chest or abdomen, 
there is reason to hope that, however characteristic the brain 
symptoms may appear to be, the inflammation is simple ; on 
the other hand, when such evidences of scrofulosis exist, there 
is great reason to fear that the disease is granular meningitis. 
When, in addition to the scrofulous or tuberculous diathesis, 
the disease is protracted to two or three weeks, or more, the 
proof of its scrofulous nature may be regarded as conclusive. 



See Am. Horn. Obs., vol. vii, p. 59. 



6S 



PRACTICE OF MEDICINE. 



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JO PRACTICE OF MEDICINE. 

Treatment. The remedies which will be found most use- 
ful in the early stages of acute hydrocephalus are: ACONITE, 
Belladonna, Glonoine,* and Mercurius. Bell, alone, or 
the alternate use of Aeon, and Bell., ox Bell, and Glo., in the first 
and second stages, and of Bell, and Merc, in the second and 
third, with proper attention to hygienic influences, will often 
prove successful in arresting this very formidable disease. The 
special indications for the employment of these and other suit- 
able remedies, have already been given under the heads of 
Cerebral Hyperoemia and Me?tingitis, whose symptoms corres- 
pond to the curative stages of this disease, and to which 
reference should be made for the requisite treatment. Nor, 
considering the scrofulous nature of the affection, should the 
remedies suitable to that condition, mentioned under Scrofula 
and Tuberculosis, be overlooked. 



CHRONIC HYDROCEPHALUS. 
dropsy of the brain. 

Chronic Hydrocephalus, unlike most chronic affections, 
bears no affinity whatever to the acute, the latter being 
an inflammatory disease, modified by constitutional and local 
causes, while the former, as its name imports, is a true 
dropsy of the brain, consisting of an accumulation of water or 
serum within the ventricles and membranes of the brain. It is 
almost entirely confined to children, and is both congenital and 
acquired. Congenital cases are comparatively rare ; and owing 
partly to mechanical violence, and, in some case, to defective 
development of the cerebral mass, generally prove fatal at the 
time of birth. Extra-uterine cases generally manifest them- 
selves during infancy, or soon after birth, before the fontanelles 
are closed, and while the cranium is capable of expansion. 

Enlargement. The chief feature in these cases, and 
that which first attracts attention, is the enlargement of the 

*A m. Horn, 05s., vol. vii, p. 60. 



CHRONIC HYDROCEPHALUS. 7 1 

head. This takes place gradually in every direction, except at 
the base of the cranium, but is the most prominent in the 
frontal, temporal and occipital regions. As a general rule, the 
face is but little, if any enlarged, so that the front and sides 
project in such a manner as to give the head a remarkably 
wedge-shaped appearance, resembling an inverted cone or 
pyramid. Sometimes, however, the enlargement takes place 
equally in every direction, giving to the head the appearance 
of an immense animated ball, too heavy to be supported with- 
out some external aid. 

Symptoms. Aside from the enlargement, which from the 
first is generally quite manifest to the eye, the earlier symp- 
toms are sometimes difficult of recognition. The increased 
weight of the head, however, no less than the functional dis- 
turbance of the oppressed brain, give to the child a somewhat 
uncertain and tottering gait, which is characteristic of the dis- 
ease. After a while the symptoms become more pronounced ; 
the child becomes dull and peevish ; tremors of the limbs set 
in, so that he can no longer walk ; the senses gradually fail ; 
there is more or less insensibility of the skin ; taste becomes 
perverted and weak ; the sense of smell is diminished ; dim- 
ness of vision follows ; and finally hearing itself fails. The 
digestive functions generally remain longer unimpaired, but 
they, too, at last become involved ; vomiting occurs, and ema- 
ciation, notwithstanding an increase in the amount of food, is 
likewise produced. Costiveness and scanty urine are also at- 
tendant symptoms. At last, symptoms of paralysis set in ; 
the eyes are turned to one side, the pupils are dilated, and 
vision becomes extinct. The rectum and bladder become im- 
plicated, so as to lose all control over their contents. Finally, 
after successive attacks of spasms and convulsions, the paraly- 
sis becomes complete ; suffocative fits occur, during which the 
breathing becomes labored and stertorous ; insensibility fol- 
lows ; the pulse becomes small, feeble and intermittent ; and 
death closes the scene. 



72 PRACTICE OF MEDICINE. 

PROGNOSIS. Although chronic hydrocephalus is gener- 
ally fatal, it is not necessarily so. A large proportion of cases 
will recover if taken in time and suitable treatment instituted. 
Indeed, there is no good reason why, at any period previous to 
the consolidation of the cranium, it should not be as amenable 
to treatment as any other form of dropsy. 

Treatment. This is either general or local. Local treat- 
ment has in the great majority of instances been productive of 
more harm than good ; and may therefore be dismissed with 
but a passing remark. Tapping is claimed to have permanently 
relieved a few cases, but the ordinary result of the measure, as 
might have been anticipated, has been to hasten, and some- 
times to cause a fatal termination, by exciting inflammation of 
the brain and its membranes. " Methodical Compression." as 
it is called, by means of adhesive strips so applied as to pro- 
duce uniform compression of the cerebral mass, after the man- 
ner of Barnard, has for the most part either proved entirely 
nugatory, or else been attended with dangerous consequences 
from compression of both the brain and the pericranial vessels; 
the practice, however, still has its advocates, and is claimed by 
its author and others to have been successful in a number of 
instances. It is only applicable to cases in which the bones of 
the cranium are loose, and the vital powers weak, and even 
then should be employed with the greatest caution, being 
abandoned whenever the symptoms of compression are aggra- 
vated by it. 

The general treatment may be gathered from the fol- 
lowing 

THERAPEUTIC INDICATIONS. 

Arsenicum. — Swelling, particularly of the head and face ; 
vomiting on being raised up in bed ; impairment of the special 
senses ; emaciation and muscular weakness ; constipation ; re- 
tention, or involuntary discharge of urine ; anxious and op- 
pressed breathing at night, or in the evening, in bed. 



CHRONIC HYDROCEPHALUS. 73 

Calcarea carb. — Scrofulous swelling ; old, pale and hag- 
gard look ; trembling and weakness of the limbs ; tottering 
gait ; emaciation and great physical prostration ; non-closure 
of the fontanelles ; constipation. 

Helleborus. — Dullness of the senses ; sopor; pale, yellowish 
face, with puffiness or swelling ; great weakness of the limbs ; 
spasms and convulsions ; small, feeble pulse ; suppression of the 
urine ; paralysis. 

Mercunus. — Great restlessness ; swelling of the head ; dil- 
atation of the pupils ; impairment of the senses ; spasmodic 
paroxysms; collapse of the system ; paralysis. 

Plumbum acet. — Heaviness of the head, with pressure as 
though the skull was too full ; dropsy ; emaciation, weariness, 
and increasing debility ; nausea and vomiting ; trembling of the 
limbs ; restlessness and sleeplessness, or somnolence and loss 
of the senses ; retention, or involuntary emission of urine ; 
pulse, small and frequent, or slow and feeble ; constipation ; 
spasmodic paroxysms and paralysis. 

Silicea. — Scrofulous swelling of the head ; feeling as though 
the head was filled with living things ; dullness of the senses ; 
pale, swollen face ; suppression of stool and urine ; great pros- 
tration and muscular weakness ; suffocative breathing ; spasm 
of the limbs ; numbness, swelling and paralytic weakness. 

Sulphur. — Scrofulous enlargement of the head ; heaviness 
and languor of the limbs ; trembling gait ; dullness of the 
senses ; pale, bloated face ; emaciation ; constipation ; reten- 
tion of urine ; paralysis. 

Zincum. — Small, weak pulse ; loss of consciousness ; cold- 
ness of the body ; great weakness and heaviness in the limbs, 
with tremor ; oppression of breathing ; constipation ; drowsi- 
ness; heaviness in the head ; nausea with trembling and tend- 
ency to paralysis. 

Diet and Regimen. — The diet should be light and nutri- 
tious, consisting of such articles as milk, oatmeal porridge, 



74 PRACTICE OF MEDICINE. 

wild game, lean, tender, broiled beef, oysters, and soft boiled 
eggs, etc. Care should be taken to give the child the advantag- 
es of sufficient light, air and exercise, carefully guarding it from 
exposure to the action of all depressing agents, or to bodily or 
mental excitement. In short, everything possible should be 
done to invigorate the body, and to guard against any prema- 
ture development of the mental faculties. 

CEREBRAL APOPLEXY. 

The term Apoplexy, from a Greek word, signifying / strike, 
is used to denote a sudden loss, more or less entire, of sensation, 
consciousness, and voluntary motion, depending upon cerebral 
pressure produced by congestion or extravasation within the 
cranium ; the circulation and respiration being continued. This 
definition is perhaps as perfect as any that can be framed ; yet 
the attack is not always sudden, the condition sometimes set- 
ting in gradually, even when produced by cerebral hemorrhage. 

PATHOLOGY. — All cases of true apoplexy are caused by hy- 
peraemia of the brain, by cerebral hemorrhage, or by sudden 
effusion of serum within the cranium ; hence some pathologists 
have divided the disease into three varieties, the simple or con- 
gestive, the sanguineous or hemorrhagic, and the serous. These 
distinctions, however, are of but little practical importance, since 
it is generally impossible to determine with certainty, previous 
to the death of the patient, which of the three conditions exist 
in any particular case ; and since, moreover, in consequence of 
the pressure which they alike exert upon the brain, the symp- 
toms in either case are similar. 

Some pathologists restrict the term apoplexy to cases of 
cerebral hemorrhage alone ; but although such cases are much 
the most frequent, nothing is more certain than that death oc- 
casionally occurs with all the symptoms of apoplexy, in which 
the only observable lesions of the brain are : a greater or less 
amount of hyperaemia of the cerebral vessels, or an abnormal 



CEREBRAL APOPLEXY. 75 

effusion of serum into the ventricles, or into the cavity of the 
arachnoid. As just stated, however, the most common lesion in 
cerebral apoplexy is hemorrhage, the blood being effused either 
upon the surface of the brain or its membranes, in the ventricles, 
or in the cerebral tissue itself. As would naturally be inferred, 
the principal seats of hemorrhage are those portions of the 
brain most abundantly supplied with blood vessels, such as the 
corpora striata, optic thalami, etc. The quantity of blood ef- 
fused varies from a few drops to several ounces. It is some- 
times infiltrated into the adjoining tissues, producing more or 
less suppuration, laceration and softening of the cerebral struct- 
ure; but generally it is collected into one or more separate 
cavities, corresponding to the points of rupture in the cerebral 
vessels. The extravasated blood gradually undergoes absorp- 
tion, disappearing in some cases in the course of five or six 
months ; in others it becomes encysted and may continue sev- 
eral years. The number of coagula generally corresponds with 
the number of sanguineous effusions which have at different 
periods occurred ; no less than a dozen clots, in different stages 
of absorption, having been found in the same brain. These 
facts are of the greatest interest and importance, as showing 
how nature at once sets up a process of reparation, which if 
properly encouraged, and not interfered with by depletion, or 
other depressing treatment, is capable of effecting a complete 
restoration of the injured organs. 

ETIOLOGY. — The chief predisposing causes of cerebral apop- 
lexy are inheritance and old age. Statistics show that it attacks 
the descendents of apoplectic parents much more frequently 
than others, owing either to a similarity of physical conforma- 
tion, or, which is more likely, to some inherited weakness of 
the system, the existence of which in the parents constitutes the 
original predisposition to the complaint. Old age, however, is 
the principal predisposing cause, and is doubtless the most pow- 
erful, as the great majority of cases occur beyond the age of 



76 PRACTICE OF MEDICINE. 

fifty. Hence, people advanced in life, especially if they are, or 
have been very hard thinkers, or addicted to excesses of any 
kind, are very apt to be cut off in this manner. For these reas- 
ons, women, whose habits of life are generally more regular 
than those of men, are less liable to the complaint. Cardiac 
affections are supposed to favor the disease by causing more or 
less hyperaemia of the brain, and when other circumstances con- 
cur to produce it, no doubt they contribute to the result. The 
same may be said of the state of the system denominated 
plethora, arising from free living and sedentary habits. 

Although the exciting causes of cerebral apoplexy are 
numerous, they can be reduced to a very few heads. Whatever 
tends to produce congestion of the brain, such as exposure to 
the sun's rays, violent mental emotion, heavy lifting or strain- 
ing, hard coughing or vomiting, playing upon wind instruments, 
excessive venery,the free use of alcoholic stimulants, compression 
of the vessels of the neck, dependent position of the head, as in 
in stooping, etc. To these may be added repelled eruptions, an 
overloaded state of the stomach, the sudden suppression of 
habitual discharges, and exposure to either excessive heat or 

cold. 

DIAGNOSIS. — Cerebral apoplexy is liable to be confounded 
with both syncope and coma. In syncope, however, the sur- 
face is pale and cold, the features are contracted, the pulse is 
lost at the wrist, and the respiration is suspended ; in apo- 
plexy, on the other hand, the very reverse occurs. Coma, from 
the great resemblance of its symptoms to those of apoplexy, 
can only be distinguished from it by the cause, which in cases 
of apoplexy generally depends upon sudden pressure on the 
brain, while in other cases it is symptomatic of narcotic poison- 
ing, inebriation, cerebral inflammation, hysteria, etc. The diff- 
erences between these affections and true apoplexy are so 
great, that notwithstanding the similarity of their general ap- 



CEREBRAL APOPLEXY. 77 

pearance, a mistake in diagnosis would be alike discreditable to 
the practioner and injurious to the patient. No such error, how- 
ever, can occur if sufficient attention is paid to the symptoms. 

PROGNOSIS. — Cerebral apoplexy is always a serious disease, 
and, sooner or later, generally proves fatal. This is especially 
true of cases caused by effusions or extravasations within the 
cranium. On the other hand, cases depending on cerebral 
hyperemia merely, without serous effusion, vascular extravasa- 
tion, or other lesion, may be regarded favorably. But as it is 
usually impossible, particularly soon after the attack, to deter- 
mine these questions with any degree of accuracy, the progno- 
sis is always more or less doubtful. 

As a general rule, it may be stated, the danger to life is 
proportional to the extent of the paralysis ; and is greatest 
when, in addition to the mental functions, the paralysis involves 
the organs of circulation and respiration. Among the more im- 
portant signs threatening a fatal issue are : protracted coma, 
convulsions, general paralysis, dilated pupils, obstructed respir- 
ation, foaming at the mouth, frequent vomiting, coldness and 
clamminess of the surface, and involuntary evacuations. Still, 
if the vital powers are husbanded, the patient may possibly sur- 
vive even these formidable symptoms, though it must be con- 
ceded, that if the patient escape for the time, he is very liable to 
sink sooner or later, either from a recurrence of the attack, or 
by a general failure of the vital powers resulting from the injury 
done to the brain. If, however, the patient survive the first on- 
set of the disease without any subsequent aggravation of the 
symptoms, there will always be room for hope, even when ex- 
travasation of blood has taken place. But it should be remem- 
bered in this connection, that about the eighth or tenth day of 
the seizure is a critical period, for then inflammation sets in 
about the clot, and may destroy the patient. 



78 PRACTICE OF MEDICINE. 

Symptoms. — In the majority of cases, the attack is preced- 
ed by certain premonitory symptoms, such as pain in the head, 
ringing in the ears, impaired vision, giddiness, loss of memory, 
drowsiness, and other evidences of cerebral hyperaemia ; to 
which are added, in many cases, more or less numbness, or 
pricking, in the extremities. In other cases, the patient, pre- 
viously in apparent health, falls down insensible, with a total 
abolition of the sensorial functions, or manifests a momentary 
apprehension of impending danger, by raising his hands to his 
head, and making some alarming exclamation, at the very in- 
stant of falling. The degree to which the sensorial functions 
are affected varies. In very severe cases, sensation, conscious- 
ness, and voluntary motion, are all lost ; in others, there is a 
greater or less degree of senso-motory impairment, the patient 
being in a state of semi consciousness, sensible to outward im- 
pressions, and capable, to some extent, of voluntary move- 
ments. The pupils are at first generally contracted, frequently 
in an unequal degree ; but in some cases they are largely dila- 
ted, and insensible to the stimulus of light. More or less 
paralysis is associated with the attack, however light the stroke. 
Generally, one side of the body is motionless, constituting 
hemiplegia. The tongue is twisted towards the paralyzed side, 
deglutition is lost, or greatly impaired, respiration is slow and 
heaving, and the breathing loud and stertorous. Constipation 
and retention, or involuntary discharge of urine, are also attend- 
ant symptoms. Though the power of voluntary motion is gen- 
erally entirely lost, there is sometimes more or less rigidity or 
spasmodic contraction of the muscles, confined, of course, to the 
unparalyzed side. The pulse is sometimes slow, full and bound- 
ing ; at other times it is weak, small and intermittent. In the 
former case, there is more or less heat and flushing of the face, 
with warmth of the extremities ; in the latter, the face is pale 
and shrunken, and the extremities cold. 



CEREBRAL APOPLEXY. 79 

TREATMENT. — During the paroxysm the patient should be 
kept in such a position as will favor the return of blood from 
the head. The head and shoulders should be raised by pillows ; 
the clothing loosened about the neck and chest, and obstructed 
access of cool air to the patient's chamber at all times secured. 

The lower extremities should be kept warm by means of 
frictions, warm foot baths, flannel wrappings, etc. ; and the 
bowels emptied from time to time with lavements of tepid wat- 
er, to which may be added, if necessary, a tablespoonful or two 
of sweet oil. Attention, also, should be paid to the bladder, 
and the urine drawn off with the catheter whenever necessary. 

Diet and Regimen.— In the early stages of the attack, 
the diet should consist exclusively of gum water, barley or rice 
water, toast water, and such like farinaceous drinks ; but as the 
case advances, and improvement sets in, more nutritious sub- 
stances may be cautiously administered, such as milk, soft 
boiled eggs, beef tea, etc., provided no ill effects are thereby 
produced ; but if, on strengthening the diet, the face becomes 
flushed, and headache ensues, all stimulating articles of diet 
should be immediately withdrawn. 

THERAPEUTIC INDICATIONS. 

Arnica. — Drowsiness, with moaning and insensibility ; 
eyes staring and dim ; pupils contracted or dilated ; pulse full 
and strong ; respiration labored and snoring ; involuntary 
evacuations of faeces and urine ; paralysis, especially of the left 
side. This remedy is suitable for cases depending either upon 
extravasations or determinations of blood. 

Baryta. — Drowsiness, semi-consciousness, or coma somno- 
lentum ; obscuration of vision ; pulse small and irregular ; 
breathing short and suffocative ; frequent discharges of urine 
and faeces ; paralysis, especially of the right side ; mouth and 
tongue drawn to one side ; great restlessness and moaning. 

Belladonna. — Drowsiness, stupor, loss of consciousness ; 



80 PRACTICE OF MEDICINE. 

eyes red and staring ; pupils dilated ; pulse full and slow ; 
breathing labored, irregular and stertorous ; convulsive move- 
ments ; paralysis of limbs, tongue, etc. ; involuntary discharges 
of faeces and urine ; redness of the face and icy coldness of the 
extremities. 

Cocculus. — Vertigo, stupor, and loss of consciousness ; spas- 
modic rolling of the eyes, with the lids half closed ; dimness of 
vision ; pupils contracted or greatly dilated ; pulse small and 
hard ; breathing tight and oppressed, with snoring; frequent 
evacuations ; convulsions and paralysis, especially of the lower 
limbs ; and strong determination of blood to the head. 

Lacliesis. — Drowsiness, sopor and insensibility ; eyes dim 
and distorted ; pulse small, weak and irregular, or full and hard ; 
respiration labored, with slow, heavy, whizzing breathing ; bow- 
els generally constipated ; trembling of the muscles ; paralysis, 
especially of the left side ; and congestion to the head, with 
blueness of the face. 

Laiirocerasiis — Insensibility, with complete loss of con- 
sciousness and sensation ; eyes distorted and staring ; vision 
lost ; pupils contracted and immovable ; pulse small, slow and 
irregular ; convulsions, with subsequent paralysis, including 
paralysis of the sphincters ; great coldness, with deficient 
susceptibility to the action of remedial agents. 

Mercnrins. — Vertigo and loss of consciousness ; dilatation of 
pupils, with vanishing of sight ; feeble, slow and trembling 
pulse ; dyspnoea ; urine dark and turbid ; constipation ; spas- 
modic movements ; paralysis ; great sinking and prostration. 

Nux Vom. — Sopor, with snoring ; eyes dull and blurred ; 
pulse full and hard, or small and collapsed ; suffocative fits, or 
anxious dyspnoea ; retention of urine; constipation ; paralysis, 
especially of the lower limbs ; attacks preceded by vertigo, 
roaring in the ears, headache, etc. 

Opium. — Sopor, preceded by vertigo, cephalalgia, etc. ; 



CEREBRAL APOPLEXY. Si 

pupils dilated and insensible ; pulse, slow, weak and intermit- 
tent ; respiration slow and snoring ; constipation ; retention of 
urine ; convulsive movements, with trembling of the limbs ; red 
and puffed face ; attacks preceded by cerebral congestion 
disposition to sleep, and vacant look. 

Pulsatilla. — Drowsiness and loss of consciousness ; eyes 
dull and bleared ; pulse very weak ; respiration impeded and 
rattling ; retention or incontinence of urine ; constipaticn ; ex- 
cessive debility and trembling ; crimson hue of the face, with 
swelling ; and, if occurring at or before the climacteric period, an 
arrest or disturbance of the menstrual functions. 

Stramonium. — Vertigo, stupor and insensibility ; pupils 
dilated and insensible ; pulse small, irregular and almost ex- 
tinct ; deep stertorous breathing ; frequent blackish stools ; 
involuntary emissions of urine ; spasmodic rigidity and trem- 
bling ; loss of sense and of voluntary motion, with suppression 
of all the secretions. 

Zinc. met. — Great drowsiness, with frightful dreams, or 
stupor ; weariness, with vanishing of sight ; quick and irregular 
pulse ; spasmodic dyspnoea ; retention of urine ; constipation ; 
paralytic weakness, heaviness and trembling ; cold hands and 
feet, stupefying headache, and livid face. 



COUP de SOLEIL ; SOLIS ICTUS-SUNSTROKE. 

Sunstroke may be defined to be a paralysis of the cere- 
bral functions caused by heat, the result, generally, of long con- 
tinued exposure to the direct rays of the sun. It is a disorder, 
which, so far as the general symptoms are concerned, bears a 
close resemblance to apoplexy ; indeed, until within a recent 
period, it has commonly been regarded as a species of that dis- 
ease. Since, however, the term is used to denote two different 
conditions, namely, true sun stroke and ther7nic exhaustion, it is 



%2 PRACTICE OF MEDICINE. 

well to remember, that while the former is distinguished by in- 
tense fever, the temperature ranging from 108 to 112 , togeth- 
er with symptoms denoting a profound depression of the ner- 
vous system, such as insensibility or loss of consciousness, dys- 
pnoea, lividity of the face, stertorous breathing, coma, convul- 
sions, paralysis, etc. ; the latter, on the contrary, is character- 
ized by faintness, or a tendency to syncope, a pallid countenance, 
a pale, cool and moist skin, and a rapid but feeble circulation. 
SYMPTOMS. — The attack is generally preceeded by certain 
premonitory symptoms, such as excessive thirst, more or less 
giddiness or vertigo, a sense of faintness, frequent disposition 
to urinate, stupidity, and sometimes drowsiness. The bowels 
are generally constipated, but sometimes diarrhoea occurs, es- 
pecially in the case of children. Unless relieved, the patient 
either gradually or suddenly, falls into a state of insensibility, 
attended with coma, stertorous breathing, convulsions, etc. ; 
or he is attacked with syncope, which not unfrequently proves 
immediately fatal. 

ETIOLOGY. — A hot, moist* and close atmosphere, over 
exercise, tight and unreasonable clothing, the breathing of 
vitiated air, and whatever tends to produce suffocation, all con- 
spire to produce an attack ; especially if there be superadded, 
great bodily fatigue, a heated atmosphere, or prolonged expos- 
ure to the direct rays of a tropical sun. Hence, soldiers serving 
in hot climates often suffer from sunstroke, their warm, tight- 
fitting uniforms, heavy accoutrements, and long, weary marches, 
predisposing to, and frequently precipitating such attacks, es- 
pecially when exposed to the rays of a burning sun. 

Dr. R. R. Gregg, of Buffalo, the author of what is known 

* " When the air is already charged with vapor, evaporation takes place slowly. Hence 
the deadly nature of heat and moisture when combined. The evaporation from 
the skin being checked the body has lost its power of cooling itself. In these facts is to 
be found the explanation of the circumstance, that in the dry air of southern central Africa, 
sunstroke is least frequent, whilst it is most fatal in the moist climate of the low plains of 
India. Moisture in the air is therefore a favoring circumstance for the production of sun- 
stroke."— Dr. H. C. Wood, Jr. 



COUP DE SOLEIL. 83 

as the "vapor theory!' assumes the cause of sunstroke to be 
" pressure upon the brain by vapor generated from the water of 
the blood by the excessive heat of the body that exists in such 
cases." This may possibly be true, at least in some cases, but 
as it is a mere hypothesis, it is not entitled, in the present state 
of our knowledge on the subject, to any great weight. One 
thing, however, is certain, the true and only known cause of sun- 
stroke is heat, and heat alone, but the modus operandi of its ac- 
tion has not yet been demonstrated. 

PATHOLOGY. — As already remarked, the opinion was long 
entertained, that sunstroke is simply a form of congestive apop- 
lexy. Hence, the old, but generally fatal treatment by bleed- 
ing. It is now known that the chief pathological state is one of 
extreme pulmonary congestion, the brain itself being in a nor- 
mal or nearly normal condition. This fact is well illustrated 
by the post-mortem appearances in the three fatal cases observ- 
ed by surgeon Russel, of the 68th regiment of British troops 
stationed at Madras, and described by him in a communication 
read before the London College of Physicians, and afterwards 
published in the Medical Gazette. " The brain," he says, " was, 
in all, healthy ; no congestion or accumulation of blood was ob- 
servable ; a very small quantity of serum was effused under the 
base of one, but in all three tlie lungs were congested even to 
blackness througJi their entire extent ; and so densely loaded 
were they, that complete obstruction must have taken place. 
There was also an accumulation in the right side of the heart, 
and the great vessels approaching it."* In these, as in other 
cases, death resulted from asphyxia. 

Treatment. — The burning temperature of the surface, es- 
pecially of the head and neck, should be reduced as quickly as 
possible by the free application of cold water, ice, cool air, etc., 
to the surface, at the same time that the great nervous depress- 



* Graves' " Clinical Medicine," Th'd. Am. Ed. s p. 118. 



84 PRACTICE OF MEDICINE. 

ion, and consequent embarrassment of the circulation, is over- 
come by the cautious administration of stimulents. Whenever 
practicable, the cold effusion to the head, neck and shoulders, 
continued until the temperature sinks to 98 or ioo°, is the 
most speedy and effective way of rescuing the patient from his 
state of extreme danger. The same end, also, may be speedily 
and safely accomplished by the judicious use of warm water, so 
applied as to promote evaporation from the surface.* Thermic 
exhaustion on the contrary, and the various complications and 
sequelae, such as convulsions, nausea, vomiting, meningitis, etc., 
will be best met by time — which is an essential element of cure 
in most cases — aided by suitable internal medication, agreeable 
to the following : 

THERAPEUTIC INDICATIONS. 

Aconite. — Burning heat, especially in the head and face, 
with burning dryness of the skin, excessive thirst, redness of 
the eyes and cheeks, restlessness and anxiety, nausea, vertigo, 
and headache aggravated by warmth. 

Aconite is well adapted to relieve the sufferings excited by 
sunstroke, or by exposure to intense heat, and also to guard 
against the dangers of excessive reaction ; but it should never 
be employed in a low form at least, until the period of greatest 
depression is fully passed. 

Antimonium tart. — The leading indications for the use of 
this remedy are similar to those given for Aconite, and it should 
be used with the same precautions ; but it is more especially in- 
dicated when, in addition to those symptoms, there is much 
gastric disturbance, great prostration, languor and sense of ex- 
haustion, or when attended with syncope, convulsions, or 
paralysis. 

Belladonna. — This remedy is indicated whenever brain 
symptoms predominate, such as severe headache, vertigo, deliri- 



See Am. Horn. Ois., vol. vi, p. 55. 



COUP DE SOLEIL. 85 

um, sensitiveness to light and sound, great anguish, etc., and also 
when the attack is sudden, the patient falling down insensible, 
as in apoplexy, with coma, stertorous breathing, lividity of the 
face, and other symptoms of cerebral and pulmonary congestion. 

Bryonia. — is indicated when, in addition to most of the 
symptoms already mentioned, there is heaviness and weakness 
of the limbs ; when the slightest exertion occasions fatigue ; 
and when there is a marked tendency to syncope, or much un- 
easiness and apprehension ; also when there is great weakness 
of digestion, with more or less nausea, vomiting and diarrhoea, 
especially in children. 

Camphor* — During the first stage, when great depression of 
both the nervous and circulatory systems exist ; also, after re- 
action sets in, provided Aconite, Belladonna and Bryonia fail 
to relieve. 

Glo?ioine. — Intense headache, with throbbing in the front, 
top and back part of the head, especially when followed by sud- 
den loss of consciousness. 

Helleborns. — Persistent headache, attended with drowsi- 
ness, or other evidence of serous effusion within the cranium. 

Hyoscyamus. — When attended with cephalalgia, sleepless- 
ness, delirium, convulsions, syncope, enuresis, or diarrhoea. 

Silicea. — Frequent micturition, obstinate constipation, 
great thirst, nausea, vomiting, and other gastric derangements. 

Veratrum vir. — Thermic fever, with great heat of skin, 
persistent diarrhoea, violent dyspnoea from pulmonary en- 
gorgement, convulsions, paralysis, or syncope. 

Diet and Regimen. — Gastric derangements, disturbances 
of the circulation, and various cerebral affections, such as 
epilepsy, insanity and paralysis, resulting from the profound de- 
pression of the nervous system, and consequent injury sustained 
by the great nerve centres, are among the more persistent 
symptoms of sunstroke, and give rise to great physical prostra- 
tion, which often lasts for years ; calling for the exercise of 



86 PRACTICE OF MEDICINE. 

sound discrimination and judgment as to diet, clothing, exer- 
cise, climate, and other hygienic influences. The food should 
be plain and of easy digestion, special regard being had to such 
articles of diet as are rich in phosphorus, such as fresh scale 
fish, raw oysters, corn and oat-meal pudding, Graham bread, etc. 
The clothing should be carefully adapted to the season, and 
the sensibility of the patient, being neither too thick and warm, 
nor too thin, since both heat and cold are oppressive and injur- 
ious.* For this reason, the patient should, if possible, go north 
in summer, and south in winter; and this should be repeated, 
if necessary, from year to year, until such time as the patient 
can bear the varying temperature of his own home. If this is 
impracticable, underclothing made of soft buck-skin, or fur, may 
be worn in winter, and such other precautions taken against the 
effects of cold and heat as the peculiar circumstances of each 
case may require. Finally, the patient should be encouraged 
by the assurance, that but few cases are so hopeless that time — 
which, as already stated, is often an essential element of cure — 
will not, in conjunction with suitable remedial measures, be at- 
tended with entire relief. 

CONCUSSION OF THE BRAIN. 

We shall close our chapter on diseases of the brain, with a 
few remarks on concussion, which though an injury instead of 
a disease, requires medical treatment for its management, and 
therefore belongs to the domain of medicine, rather than surgery, 
where it is commonly placed. 

Concussion may be defined to be, a shock communicated 
to the nervous system by some external violence, such as a 
blow or fall, whereby its functions are temporarily suspended, 
and the vital powers more or less depressed. Sometimes the de- 
pression is very slight, and the patient quickly recovers ; at 
others, the shock is so severe as greatly to impede the circula- 



* See Am. Horn. Obs., vol. ix, p. 210, et seq. 



CONCUSSION OF THE BRAIN. 87 

tion and retard recovery; while at other times the depressed 
condition continues, and the patient sooner or later sinks. In 
the more severe cases, when the system rallies, vomiting is apt 
to ensue ; this is a favorable sign, as it tends by equalizing the 
circulation to promote recovery. 

DEGREE OF INJURY. — As might be inferred, every degree 
of injury has been observed in fatal cases. Sometimes actual 
rupture occurs ; at others, a soft or semi-diffluent state is pro- 
duced ; while in other cases, even in those in which the shock 
and consequent depression are the greatest, no lesion whatever 
can be discovered. In these cases, no doubt, the patient dies 
from the effects of the shock alone ; while in the others, the in- 
jury to the brain interferes with the circulation through it, and 
though the effects of the concussion upon the general system 
may be no greater, the character of the injury is such as to 
permanently depress the vital powers,and death, sooner or later, 
is the inevitable consequence. 

FINAL RESULTS. — The final results of the injury are as 
various as the immediate effects. As we have said, some cas- 
es soon recover ; others rally slowly, the paralysed brain grad- 
ually regaining its power and functions ; and the patient, after 
remaining, it may be, for hours in a cold and semi-moribund 
condition, slowly recovering his activity and senses ; but suffer- 
ing for a longer or shorter period from headache, confusion of 
thought, giddiness, and impairment of the mental powers. In 
other cases, again, should the patient survive the immediate 
effects of the injury, an irritable state of the brain may re- 
main, or such an impairment of its functions, as to render it 
liable to inflammation under the operation of almost any ex- 
citing cause, such as excess in eating and drinking, mental 
emotion, etc. 

Symptoms — The symptoms of concussion are, generally, a 
greater or less degree of pallor, coldness, flaccidity of the mus- 
cles, and insensibility. Commonly, all power of motion is 



88 PRACTICE OF MEDICINE. 

lost ; and if the patient is capable of being partially aroused, 
he immediately relapses again into a stage of semi-unconscious- 
ness or insensibility. In this stage the pulse is slow and feeble, 
the pupils contracted, and the surface pale and cold. The sec- 
ond stage is characterized by returning warmth and color, the 
restoration of consciousness and the power of motion, and the 
gradual re-establishment of the circulation. This stage is gen- 
erally accompanied by more or less vomiting, depending upon 
the severity of the concussion. The third stage is marked by 
extreme physical prostration, a cold, clammy, semi-moribund 
condition, continuing sometimes for hours, and at last gradually 
yielding to recovery, or terminating in death. 

Treatment. — This should be directed, first of all, to over- 
coming, as speedily as possible, the depression of the vital pow- 
ers, being careful at the same time not to over-stimulate 
the circulation, but simply aiming at the re-establish- 
ment of the normal condition. This can generally be best 
effected by wrapping the patient in warm blankets, applying 
friction to the surface, and using dry heat* to the extremities 
etc. As soon as the patient is able to swallow, he may be al- 
lowed to drink moderately of simple warm teas ; but alcoholic 
stimulants should be carefully avoided, unless the depression is 
so great as to imperatively demand their administration, when 
the quantity should be regulated by the exigencies of the 
case. 

The chief remedies for concussion, together with the lead- 
ing Therapeutic Indications, are given in the subjoined 
table. Consult, also, Table XII, and the Therapeutic In- 
dications, under the head of Apoplexy. 



* In the case of young children, the warm bath, or hot foot bath, may be used with the 
greatest advantage, care being taken to prevent the patient getting chilled during its administra- 
tion ; but in the case of adults, dry heat is generally the handiest as well as the safest mode of 
applying heat to the surface, the patient being surrounded by hot bottles, or some equivalent 
substitute. 



CONCUSSION OF THE BRAIN, 89 

TABLE XL 

CONCUSSION. — SYNOPSIS OF TREATMENT. 

i. Premonitory Symptoms. — Bell., Dig., Euphor., Hep. 
Ign., Phos. ac, Rut., Sulph., Verat. 

2. First Stage, — Arn., Ars., Cic, Cocc., Con., Laur., 
Verat. 

3. Second Stage. — Arn., Bry., Chin., Euphor, Hep., Ign., 
Nux. v., Op., Phos., Rhus., Sulph., Verat. 

4. Third Stage. — Ang., Cic., Cocc, Con., Dig., Ign., Iod., 
Merc, Phos. ac, Rhus., Sulph., Zinc 

5. Muscular System. — Ang., Calc, Euphor., Iod., Phos. 
ac, Puis., Sulph., ac. ; trembling — Aug., Cic, Cin., Hep., Ign., 
Nux. v. ; spasms — Arn., Ars., Cocc, Con., Laur., Rhus., Sulph., 
Verat., Zinc ; paralysis — Ang., Calc, Cin., Euphor., Hep., Ign., 
Puis., Rut., Sulph. ac. ; tendency to paralysis. 

6. Sensorium. — Dig., Euphor., Hep., Ign., Phos. ac, Rut., 
Sulph., Verat. ; giddiness — Aug., Cin., Con., Iod., Puis., Rhus., 
Sulph. ac ; drowsiness — Arn., Ars., Calc, Cic, Cocc, Laur., 
Merc, Zinc. ; insensibility and u/iconsciousuess. 



90 PRACTICE OF M EDICINE. 

TABLE XII. 

CEREBRAL DISEASES AND REMEDIES. 

A. HYPEREMIA.— Acon., Arn., Bell., Bry., Coff., 
Merc, Nux. v., Op., Puls., Rhus., Verat., Anac,Calc,Cham. y 
Chin., Con., Dig., Dulc, Ign., Ipec, Lyc, Phos., Sil., Sulph., 
Camph., Caps., Coloc, Hyos., Sep., Spig , Tart., e. 

B. ANEMIA.— Ars., Chin., Fer., Nat., Puls., Staph., 
Cafe, Carb. v., Cin., Hep., Kal., Lyc, Lack., Merc, Nat. m., Nux. 
v., Phos., Phos. ac., Sep., Si/., Sulph., Verat., Arn., Bell., Bry., 
Cham., Nit. ac, Rhus. 

C. VERTIGO.— Acon., Arn., Bell., Bry., Lyc, Nat., 
Nux. v., Petr., Phos., Rhus., Calc., Camph., Cann., Carb. v., 
Cocc., Dig., Graph., Ipec, Nat. m., Nit. ac., Op., Puis., Sec. c, 
Thuja., Verat., Amb., Merc, Mosch.. Phos. ac, Strain. 

D. STUPOR.— Ant. t., Cro., Op., Verat., Ant. c, Bell., 
Brom., Camph., Cic, Con., Hell., Lact., Later., Phos. ac, Puis., 
Plumb., Stram., Zinc, Arn., Ars., Bar. c, Caus., Cocc, Dig., 
Lach., Led., Phos., Sec. c, Sep. 

E. INSOMNIA.— Calc, Camph , Cham., Chin., Coff., 
Kal., Lyc, Merc, Mosch., Puls., Rhus., Sep., Ars., Bell., 
Bry., Cin., Con., Fer., Hep:, Hyos., Nat., Sil., S?dph., Aeon., 
Anac, Cann., Caus., Dig., Dulc, Ign., Lach., Led., Nat. m., Nit. 
ac, Nux. v., Phos., Plumb., Sang., Spong., Thuja., Verat. 

F. CEPHALALGIA.— Acon., Bell., Cim., Coloc, 
Glon., Merc, Nux. v., Puls, Sang., Stram., Bry., Calc, 
Cham., Chin., Igna., Ipec, Sep., Camph., Caps., Cupr., Con., 
Dulc, Hyos., Op., Rhus., Sil., Spig., Sulph., Tart, e., Tong., 
Verb., Vio. t., Ver. v. 



CEREBRAL DISEASES. 91 

G. MENINGITIS.— Acon., Bell., Bry., Hel., Hyos., 
Op., Stram., Sulph., Ars., Arn., Campli., Cauth., Chi., Con., 
Cupr., Dig., Lack., Merc, Rhus., Coff, Crot., Glon., Nux. v., 
Phosp., Puis., Sil. 

H. CEREBRITIS.— Acon., Ars., Bell, Glon., Iod., 
PLUMB, Am., Bry., Hyos., Hep., Sulph., Con., Merc., Phos., 
Rhus., Crot, Coff, Nux. v. Puis, Ver. 

/. ACUTE HYDROCEPHALUS.— Acon,, Arn, Ars, 
Bell, Bry, Hel, Merc, Sulph, Cin., Con., Dig., Hyos., 
Lach., Merc., Op., Stram., Coff., Nux. v. Puis, Ver. 

J. CHRONIC HYDROCEPHALUS.— Ars, Calc, 
Hel., Merc, Plumb, Sil. Sulph, Zinc, Apoc. a., Apoc. c, 
Ascl. s., Collin, c, Dig., Equiset., Eup. p., Junip. Sumb. 

K. APOPLEXY.— Arn, Bar. c. Bell, Cocc, Lach, 
Nux. v. Op, Puls, Acon., Anac, Ant. t., Coff., Con., Dig., 
Hyos., Ipec, Laur., Merc, Strain., Zinc, Ant. c, Ang, Calc.) 
Cin, Ign, Iod, Verat. 

L. COUP DE SOLEIL.— Acon, Ant. t. Bell, Bry, 
Camph, Glon, Helleb., Hyos., Sil, Ver. v, Carb. v., Nux. 
v.. Op., Thuj., Zinc, Amyl. n., Gels., Scut. 1. 

M. CONCUSSION.— Arn., Ang., Ars., Bell., Calen, 
Cic, Con, Euphor., Hep., Merc, Petr, Puls., Rhus., Rut., 
Sulph., Verat., Calc, Cin., Cocc, Dig., Ign., Iod., Laur-, Op., 
Coff-, Hyos., Ipec, Stram., Zinc. 



92 PRACTICE OF MEDICINE. 



CHAPTER II 



DISEASES OF THE PROSOPON, OR FACE. 

SECTION I. 

PROSOPALGIA, OR FACE-ACHE. 

TIC DOULEUREUX; NEURALGIA TRIGEMINI. 
As we shall find it most convenient to describe the various 
forms of neuralgia in their anatomical, rather than in their 
physiological relations, this will be the proper place to treat of 
one of its most common and painful varieties, namely, prosopal- 
gia, or, as it is generally termed, tic douleureux y or face-ache. 
This is, for the most part, an affection of the trigeminus, or 
fifth pair of nerves ; but inasmuch as the portio dura, after pass- 
ing through the parotid gland, is connected with a twig of the 
trigeminus, the pain is sometimes, though rarely, felt also in the 
course of that nerve. Commonly but one branch of the trige- 
minus, the superior maxillary of one side, is affected ; but not 
unfrequently two, and sometimes all three of the branches are 
involved ; and the pain, by implicating the opposite branches, 
may even extend to the other side of the face. 

Symptoms. — As already stated, the most frequent form of 
prosopalgia is that involving the middle branch of the trigemi- 
nus. The pain is generally first felt in or near the infraorbital 
foramen ; and being seated in the nerve of that name, extends 
to the inner canthus of the eye, the lower eyelids, the muscles 
about the zygoma, those of the cheek, especially the buccinater, 
the upper lip and the alae of the nose. Subsequently the trunk 
of the nerve, and the branches given off from it in its passage 
through the infraorbital canal, become affected, the pains being 
felt in the palate, tongue, zygomatic fossa, the upper teeth and 
the nasal cavity. As the disease progresses, the pain may ex- 
tend, as in other forms of prosopalgia, to all parts of the face- 



PROSOPALGIA. 93 

The pain is never continual, but occurs in paroxysms of greater 
or less violence and duration. When fully formed, the 
paroxysms are frequently attended by a copious salivation. 

Next in order of frequency, the pain commences near the 
supraorbital foramen, and extending outward along the branches 
of the frontal nerve and its ramifications, is experienced in the 
soft parts covering the anterior portion of the cranium ; or it 
may extend in the opposite direction along the trunk of the 
nerve, and be felt at the bottom of the orbit. Subsequently, 
the tunica conjunctiva and adjacent parts become affected, pro- 
ducing redness of the conjunctiva and lids, with more or less 
lachrymation and swelling. Sometimes it causes extreme 
photophobia, the eye becoming so exceedingly painful and 
sensitive to light, that the patient can scarcely tolerate a single 
ray. Finally, as in other cases, the pain passes beyond the 
parts supplied by the frontal nerve, extending itself to the 
supraorbital, the maxillary, and sometimes, through communi- 
cating filaments, to the facial, temporal and occipital nerves. 

Less common than either of the preceding, but, when con- 
firmed, equally intense and obstinate forms of prosopalgia, is 
that affecting the inferior maxillary nerve. The pain is gener- 
ally first felt at or near the anterior mental foramen, and ex- 
tends to the teeth, lower lip, chin, temple and neck. As in the 
preceding forms of the disorder, the associated branches of the 
trigeminus, as well as the portio dura of the seventh, frequently 
become implicated, and then the paroxysms of pain become 
more or less general over one side of the face and head. 

When the motor nerves become implicated, the muscles 
supplied by them twitch convulsively, producing distortion of 
the features, and, in some cases, more or less spasmodic action 
of more distant parts ; the latter being caused, doubtless, by the 
extreme pain. The irritability of the affected nerves frequently 
becomes so great during the paroxysms, that the impressions 
produced merely by movement, as in talking, sneezing and 



94 PRACTICE OF MEDICINE. 

chewing, or by currents of cold air, etc., are often sufficient to 
renew the attacks. The pains are of a shooting, rending or 
burning character ; and when the paroxysm is at its height, 
they frequently become so intolerable, that the patient is utter- 
ly unable to suppress his cries. 

DIAGNOSIS. — Prosopalgia is very liable to be confounded 
with hemicrania and rheumatism. From the former it may be 
distinguished by the seat of the pain corresponding accurately 
with the course and distribution of the affected nerves ; and 
from the latter, by the exacerbation being provoked by the 
slightest touch, by the limited duration of the paroxysm, and 
by the intolerable character of the pain. From ordinary tooth- 
ache it may be distinguished by the transient character and 
rapid succession of the pains, the convulsive twitchings of the 
muscles, and the coursing of the pains along the tracks of the 
affected nerves. With reference to those cases in which the 
portio dura of the seventh pair of nerves becomes implicated, 
they are sometimes exceedingly difficult to distinguish from 
those in which only the branches of the trigeminus are involved. 
The chief difference is, the pains are no longer confined to the 
course of the trigeminus, but, in consequence of its communica- 
tion with the other nerves of the face, the agony soon becomes 
general over the entire side of the head. 

Etiology. — The causes of this affection are generally 
very uncertain and obscure. Sometimes, particularly when 
the main trunk is affected, it can be traced to tumors, or 
bony growths, pressing upon the affected nerves ; and occa- 
sionally the attack can be satisfactorily referred to such 
causes as wounds, decayed teeth, the suppression of accus- 
tomed discharges, rheumatism, gout, syphilis, poisonous 
cosmetics, etc ; but in the majority of cases, no known cause 
can be assigned. Even the most careful anatomical and 
pathological investigations generally fail of eliciting any satis- 
factory explanation. True, the affected nerves are sometimes 



PROSOPALGIA. 95 

found red and inflamed, but the ordinary absence of fever, the 
sudden, transient, and intermittent character of the attacks, 
their frequent occurrence in debilitated states of the system, 
and the usual absence of tenderness on pressure, are suffi- 
cient proofs that the cause, whatever it may be, is not gen- 
erally of an inflammatory character. Probably the most fre- 
quent exciting cause is cold. Next to this, those causes which 
induce cephalagia, such as mental emotion, severe mental and 
physical labor, excess in eating and drinking, the abuse of 
spirituous liquors, tea, coffee and tobacco, excessive venery, 
etc., no doubt contribute greatly to produce it in those who are 
predisposed to the affection. What particular class of persons 
are predisposed to it, however, is not so clear. It is doubtful 
whether sex has any special influence in this direction, as some 
suppose, though there are peculiarities in the female constitu- 
tion which undoubtedly predispose it to other forms of neural- 
gia, especially such as have their origin in the spine. Probably 
what is called the nervous temperament, or an excitable dispo- 
sition, furnishes as strong a predisposing cause as any of which 
we have any knowledge. 

PROGNOSIS. — The possibility, or even the probability of 
a cure, depends upon a variety of circumstances. When caused 
by malarious influences, general debility, pernicious habits, or 
by cold, a cure is generally easily effected ; but when, on the 
other hand, structural changes, such as tumors and other morbid 
growths, give rise to it, there is but little hope of relief. Even 
in the milder forms of the disease, the patient frequently re- 
mains more or less subject to the complaint as long as he lives. 
Death very seldom results from the attacks, however severe 
the paroxysms ; but it always has a more or less pernicious 
effect upon the system, undermining the general health, and 
rendering the mind feeble and the nervous system extremely 
sensitive and irritable. 



96 PRACTICE OF MEDICINE. 

Treatment. — It follows from the purely subjective char- 
acter and limited range of the symptoms, that the treatment of 
prosopalgia needs to be conducted with special reference to 
the cause. Hence it becomes necessary, first of all, to institute 
a careful scrutiny into the general state of the patient's health, 
his habits and surroundings, traveling, as it were, beyond the 
boundaries of the symptomatic indications,in order to ascertain, 
if possible, the true cause of the malady. In this way the pre- 
scriber is enabled to make his anatomical, physiological and 
pathological knowledge contribute not only to the diagnosis, 
but, in a large proportion of cases, to the cure of this obscure, 
obstinate and very painful disease. Even with all the light 
which can be thrown upon it in this manner, the practitioner 
will often have great difficulty in selecting a suitable remedy, 
and will as frequently be disappointed ; but it is evident that 
in no other way, in many cases, can there be any reasonable 
hope of success. Thus directed, however, the symptomatic in- 
dications are generally sufficiently definite to suggest the prop- 
er remedy ; and, as a consequence, homoeopathy has produced 
many brilliant cures in the domain of this opprobium medicorum 
of the old school. 

THERAPEUTIC INDICATIONS. 

Arsenicum. — Burning, stinging, or tearing pains in the tem- 
ples and around the eyes ; inflammation of the conjunctiva ; 
watering of the eyes ; great restlessness, distress and prostra- 
tion ; paroxysms occur, or are aggravated, in the evening or at 
night. 

This remedy is particularly useful when the attacks occur 
periodically, or when they are caused by miasmatic influences. 

Bellado7ina* — Pains of a cutting or tearing character, es_ 
pecially when following the course of the infra-orbital nerve, and 



* See Am. Horn. Observer, vol. ii., p. 108; also vol. iii, p. 66. 



PROSOPALGIA. 97 

more particularly when associated with symptoms of vascular 
excitement, such as heat, redness and swelling of the face and 
eyes, flashes of light before the eyes, and lachrymation ; also 
when there are convulsive twitchings of the facial muscles, stiff- 
ness of the neck, shooting pains in the jaws, zygomatic process 
and nose. The pains are excited or aggravated by rubbing the 
affected parts and by movement. 

Belladonna is especially applicable to cases caused by con- 
gestion or inflammation, particularly when produced by the 
abuse of mercury. 

Chininum Sulph. — This remedy is preeminently adapted 
to cases pending upon miasmatic influences. Hempel says of 
it in these cases. "Say what you please against Quinine, it is 
one of the most indispensable antidotes to the intermittent 
type of paroxysms resulting from the influence of malaria. We 
have so often and so satisfactorily cured prosopalgia with five 
or ten grains of Quinine, administered in grain doses every two 
hours during the apyrexia, that we can recommend its use to 
homoeopathic physicians with all the earnestness of one whose 
knowledge is based upon the most unimpeachable experience, 
and we advise our friends not to mind the absurd twaddle of a 
few antiquated ignoramuses, who would fain confine homoeo- 
pathy to the narrow horizon of their own childish folly." 

Although a firm believer ourself in the homoeopathic prin- 
ciple or cure, and, as a general rule,* in the adequacy of small 
doses to overcome diseased action, we can nevertheless heartily 
subscribe to these views of Prof. Hempel, deeming them by no 
means inconsistent with rational, that is to say, homoeopathic 
practice. On the contrary, as before inculcated, ( See the 
INTRODUCTION to this work ; also, remarks under the head of 
Diphtheria,) we should be greatly wanting in consistency, and 



* We say "as a general rule," because diseases depending upon mechanical, chemical 
and toxicological influences, frequently so overpower the vital force, as utterly to preclude 
the possibility of exciting in the system any permanent reaction, so long as the exciting 
cause contimies to act upon it. In such cases, it is just as absurd to expect the dynamic forces 
alone to conquer as it is for a stream of water to seek a higher level than its source. 

13 



9$ PRACTICE OF MEDICINE. 

also, as we conceive, in a proper estimate of the true sphere 
of homoeopathy, did we not strongly endorse all that he says 
on this subject. For whether the nervous system be primarily 
affected in this condition or not, it is generally admitted that, 
like a string of a puppet, its action corresponds, both in charac- 
ter and duration, to the special influences operating upon it. It 
is also admitted that Quinine is an antidote to the miasmatic 
poison. It follows, therefore, that it should be administered in 
sufficient quantity to antidote, or, if any one likes the expres- 
sion better, to counteract the poisonous principle, whether it be 
mild or severe. Nor does it alter the question, so far as the 
matter of dose is concerned, whether, the action of the poison 
on the nervous system is mediate or immediate ; whether, in 
fact, the poisonous principle acts primarily upon the blood, and 
through it upon the nervous system, thus derangeing its func- 
tions, or whether it acts in some other and more occult manner ; 
it is sufficient for us to know that a poison, sui generis, is affect- 
ing the constitution, and that a true and sufficient antidote is 
needed for it. 

Colocynthis. — Darting and tearing pains particularly on 
the left side of the face, with redness and swelling of the affect- 
ed parts ; aggravated by the slightest touch, by cold, and by 
movement of the facial muscles. 

This medicine is of great use in catarrhal cases, or when 
caused by mortified feelings, (Hartman), or by cold. 

Gelseminum. — Darting pains, especially around the eye, 
or in the course of the infraorbital nerve and dental branches ; 
also when there are twitchings and contractions of the facial 
muscles, particularly of the eyelids ; or where there is great 
nervousness, a semi-paralyzed condition of the voluntary mus- 
cles, or a distorted appearance of the eye. 

This remedy has been employed with marked success in 
periodical cases, especially of the quotidian type, (LlJDLAM.) It 
is equally valuable in catarrhal cases, if used low. 

Hepar Sulph. — Drawing and tearing pains in the cheek 



PROSOPALGIA. 99 

and temple, sometimes extending into the ears, and aggravated 
by pressure and by warmth ; also, pains in the teeth, aggravat- 
ed by contact or by eating. 

Hepar sulphuris is suitable for cases caused by the abuse of 
mercury, as in salivation. 

Iris Versicolor. — Prosopalgia involving all or any one of 
the branches of the trigeminus, especially when associated with 
"sick-headache," beginning in the morning and subsiding at 
night. 

Kalmia* — Violent rending and drawing pains in the 
cheek, with redness ; darting pains in the jaws and teeth ; and 
throbbing pains in the head. 

This medicine is said to have acted with magical effect in 
many cases of prosopalgia where all the usual remedies had 
failed, (SNELLING.) 

Mercurins. — Tearing, stinging or stitching pains, occur- 
ring in the evening or at night, and aggravated by the warmth 
of the bed ; also, facial pains caused or aggravated by carious 
teeth, or by cold, particularly if accompanied by great rest- 
lessness, wakefulness, swelling, ptyalism, or perspiration of 
the face and head. 

Mercurius is an appropriate remedy in catarrhal cases; 
also in those of an inflammatory character. 

Mezereum. — Stupefying and pressive pains, chiefly in the 
left zygomatic region, occurring in paroxysms, and extending 
over the face, head and shoulder. The pains are accompanied 
by twitching of the facial muscles ; and are aggravated or re- 
newed by warmth, especially by eating anything hot. 

This remedy is particulary applicable to cases of a syphili- 
tic origin, and also to cases arising from the abuse of mer- 
cury. 

Nux Vomica. — Rending and drawing pains in the infra-or- 
bital region, sometimes extending into the ear, with redness of 



* See Am. Horn. Obs., vol. i, p. i( 



100 PRACTICE OF MEDICINE. 

the face, or of one of the cheeks ; tingling and twitching of the 
facial muscles, lachrymation, and more or less numbness of the 
affected parts. 

Nux vomica is very suitable for coffee drinkers, particular- 
ly those of an irritable disposition ; also for cases occurring 
after a debauch, severe mental labor, watching, etc., especially 
when attended by constipation, or by derangement of the diges- 
tive organs. 

Platina. — Creeping pains, with a feeling of coldness and 
numbness, especially on the right side of the face ; renewal or 
aggravation of the sufferings at night, and during rest. 

Platina is well adapted to hysteric females, especially when 
troubled with anguish of the heart, or palpitation, or when the 
catamenia are deranged. 

Rhus Tox. — Rending, stinging, burning or drawing pains, 
especially in the supra-orbital and superior maxillary nerves; 
renewal or aggravation of the pains at night, and increased by 
the warmth of the bed, or by rest. 

This remedy is suitable to catarrhal cases, or such as are 
caused by exposure to cold and dampness. 

Sepia. — Tearing, drawing or aching pains in the face and 
nose, with swelling of the cheeks, and with or without redness 
or flushing of the affected parts. The pains frequently extend 
through the ear, especially the left, and are aggravated or re- 
newed by either hot or cold things taken into the mouth. 

This is one of the most useful remedies in the prosopalgia 
and toothache to which delicate, sensitive, nervous females are 
subject, particularly when the uterine functions are disturbed. 

Spigelia* — Violent tearing, shooting and jerking pains in 
the supra-orbital, orbital and malar regions, excited or aggravated 
by motion, contact, cold and dampness, occurring in paroxysms, 
and sometimes periodical. The pains are accompanied by more 
or less precordial anguish, lachrymation, and glossy swelling 
of the affected parts. 

Spigelia is one of the most useful remedies in prosopalgia 
especially in cases of a catarrhal or rheumatic character. 

Verbascum. — Flashing, stupefying or jerking pains, seated 
chiefly in the left zygomatic region, and aggravated by motion, 
contact and exposure to cold. The paroxysms are short but 
violent, and are often renewed by the slightest touch, and even 
by talking, chewing or sneezing. 



* See Am. Horn. Ois., vol. x, p. 237, 3d. 



PROSOPALGIA. IOI 



Consult also the following table. 

TABLE XII.— Prosopalgia/ 

Arthritic— COLOC, Merc, RHUST., Canst, Nux. v., Spig, 
Bell., Bry., Calc., Hep. s., Igna., Lye., Puis., Sep., Staph., 
Sulph. 

Catarrhal. — Bry., Coloc, Gels., Lyc, Merc, Nux. v., 
Rhus, t., Sep., Spig., Calc, Chin., Cin., Graph., Staph., Aeon., 
Caust., Cep., Cham., CofF., Phos., Puis., Sulph. 

Hysteric — Bell., Gels., Igna., Plat., Aur., Lach., Puis., 
Sep., Calc., Carb. v., Caust., Iris v., Kal., Phos., Sab., Staph., 
Sulph., Verbas. 

Inflammatory. — AcON., Arn., Bell., Bry., Merc., Phos., 
Staph., Sulph., Bar. c, Lach., Plat, Thuj., Ver. a., Calc., 
Cham., Hyosc, Nux. v., Puis. 

Mercurial.— Carb. v., Chin., Hep. s., Mez., Aur., Bell., 
Nit. ac, Sulph:, Puis., Staph: 

Nervous. — Bell., Iris, v., Kal:, Lach., Nux. v., Plat,, 
Spig., Verbas:, Caps., Hyos., Lyc, Sep., Sol. n., Aeon., Caust., 
Cham., Chelid. m., Coff., Coloc., Kal. bic. 

Odontalgic — Bell:, Cham., Gels., Merc, Nux. v., Aeon., 
Ars., Coff., Hyos., Igna., Rhus, t., Sep., Spig., Calc, Carb. v., 
Caust., Chin., Phos. ac., Sab., Staph. 

Periodical. — Ars., Chin, s., Gels., Bry., Caps., Ced., Chin., 
Nux. v., Puis., Aeon., Arn., Bell., Cauth., Calc., Carb. v., 
Caust., Coff., Con., Merc., Rhus t., Sep., Sulph. 

Rheumatic — ACON., Arn., Bry., Merc, Mez., SULPH., 
Caust., Chin., Hep. s., Lach., Nux. v., Cim. r., Phos., Puis., 
Spig., Ver. a. 



102 PRACTICE OF MEDICINE. 

SECTION II. 

DISEASES OF THE EYE. 

Ophthalmic diseases, especially those of an inflammatory 
character, have hitherto, for the most part, been regarded by 
us, as well as by many allopathists, as a single affection, where- 
as the structures which enter into the composition of the eye 
are, like those of the encephalon, so diverse as to require sepa- 
rate consideration. For what resemblance, except in a general 
way, is there between conjunctivitis, iritis, scleritis and retinitis, 
to say nothing of the various forms which even the first men- 
tioned disease assumes in different cases ? We do not propose, 
however, to describe, much less to enter into any considerable 
detail concerning many diseases to which this organ is subject — 
this must be left to special treatises — but simply to describe 
the more common forms of inflammatory and other diseases of 
the eye, in a manner sufficiently ample and accurate to enable 
one, by means of the symptomatic indications, to treat diseases 
of this organ with the same scientific precision that characteris- 
es our treat; nent of other diseases. For it must be confessed 
that, until within a very recent period, ophthalmic medicine in 
our school has not kept pace with the general advance of homoe- 
opathic practice. On the contrary, it has hitherto remained, for 
the most part, in its very infancy ;* so that our ophthalmic 
literature furnishes but a modicum of pure grain, in comparison 
with the large amount of chaff with which it abounds. This 
arises, however, from no defect in our system of practice, since 
the success which has attended the treatment of eye diseases 
under the law of similia y has been much greater than that 



* The only work we now have is Angell's " Treatise on Diseases of the Eye" the fourth 
edition of which, just published, is, I regret to say, very deficient both in description and treat- 
ment ; especially the latter. 



DISEASES OF THE EYE 103 

under allopathic treatment, as evidenced by the fact that the 
authorities have substituted the former for the latter in some of 
the great public charities ;* and also by the fact that certain 
diseases not amenable to allopathic treatment, such as incipient 
cataract, have in some instances unquestionably yielded to 
homoeopathic medication. Perhaps this very success has been 
the meansof retarding, rather than advancing.this special branch 
of medicine among us, by satisfying the demands of the public 
with less than what would have satisfied it, had the result of 
allopathic treatment been greater. 

The chief difficulties under which we labor in these cases are 
two-fold ; first, the limited number of symptoms pertaining to 
the disease, depending for the most part upon the purely local 
character of the affection ; and, secondly, the defects of our 
Materia Medica, so far as the eye symptoms are concerned, 
arising from the incomplete, careless and imperfect character of 
our provings. The latter only can be remedied, and is there- 
fore the principal road to improvement in this branch of medi- 
cal science. If under such adverse circumstances the superior- 
ity of the homoeopathic ophthalmic practice is manifest, what 
brilliant results may we not justly expect, when our Materia 
Medica shall be freed from its incomplete and unreliable symp- 
toms, and indications based upon scientific observations, be sub- 
stituted in their place ? Meanwhile, and as a humble initiatory 
effort in this direction, we shall attempt to make such use of the 
materials before use, as will fairly represent the existing state of 
our knowledge on this important subject. 

ANATOMY OF THE EYE. 

It is not necessary, nor would this be the proper place, to 
give even a general description of the anatomy of the eye, as 
every physician is supposed to be sufficiently acquainted with 



See Am. Horn. OZ>s., vol. iv, p. 386. 



104 



PRACTICE OF MEDICINE. 



both its structure and physiology. It will be well, however, 
before entering upon the study of the various affections which 
we shall have to consider under this head, to refresh the mem- 
ory by means of the following diagrams, which, in connection 
with the explanatory references, will be found to be of far 
greater practical value than the most labored description. 



i. Sclerotic coat, or sclera, 
consisting of a white, fibrous, 
dense, and somewhat elastic 
membrane, covering the pos- 
terior five-sixths of the globe, 
and giving shape and firmness 
to the organ. 

2. Chotoid, or second tunic. 
This is a thin vascular coat, 
which, like the sclera, covers 
the posterior portion of the 
eye, and is pierced near the 
centre to admit the optic 

In front it unites with, and 




HORIZONTAL SECTION OF THE RIGHT BYE. 



nerve and vessels of the retina, 
forms a part of the ciliary body and iris. The outer portion of 
this coat consists of the larger vessels, connected by a delicate 
cellular tissue, and an abundance of brownish pigment ; the 
inner portion consists of the capillary vessels of the mem- 
brane. 

3. The cornea, or "window" of the eye,* consisting of a 
transparent fibrous membrane, similar in structure to the sclera, 
covering the anterior sixth of the globe. It is composed of five 
layers ; an outer epithelial layer ; the elastic layer of Reichert ; 
the true cornea ; the layer of Descemet ; and an internal epithe- 
lial layer ; the two latter constituting the anterior or corneal 



* This is popular language only, since the pupil is the only true window, or opening of 
the eye. 



DISEASES OF THE EYE. 10 5 

portion of what is generally known as the membrane of the 
aqueous humor. The cornea, though largely supplied with 
nerves, contains no blood vessels ; consequently it never exhibits 
any appearance of vascularity, except when diseased . 

4, 5- The membranes of Descemet and Reichert. (See 
Cornea.) 

6. The iris. This is a beautifully colored vertical mem- 
brane, or curtain, attached by its margin to the ciliary processes, 
having an opening near its centre called the pupil. Its struc- 
ture is similar to that of the choroid coat, of which it may be 
regarded as an extension, just as the cornea may be considered 
an extension of the sclera ; it differs, however, from the choroid 
in being more muscular, having a circular set of muscular 
fibres for diminishing, and a radiate set for enlarging, the pu- 
pillary opening. It is abundantly supplied with nerves as well 
as blood vessels ; and is covered posteriorly with a pigment 
layer, called the uvea. 

7. The canal of Fontana or Schlemm, giving passage to a 
plexus of veins ; and generally known as the circular venous 
sinus of the iris. 

8. The conjunctiva ; a transparent and highly vascular 
mucous membrane covering the anterior portion of the globe, 
and reflected from the globe to the internal surface of the lids, 
at the ciliary margin of which it is perforated by the ciliary 
ducts. The former portion is called the occular conjunctiva ; 
and the latter the palpebral ; the posterior portion, where it is 
reflected from the globe to the lids, is frequently called the 
retro-tarsal fold\ the ciliary edge of the membrane being 
known as the tarsal conjunctiva. The entire membrane forms 
a sac, the opening of which corresponds to the edge of the 
lids. It is abundantly supplied with nerves as well as blood- 
vessels, the former being derived chiefly from the first, or 
ophthalmic branch of the trifacial. The palpebral portion is 



106 PRACTICE OF MEDICINE. 

thickly studded with papillae, which, when enlarged by disease, 
give to the membrane a villous or granular appearance. 
9. Vena vorticosa ; 10. Optic nerve. (See retina.) 
11. Intervaginal space ; 12. Lamina cribrosa. 

13. The retina, or occular expansion of the optic nerve, 
forming the internal, or third principal membrane of the eye. 
It is divided by recent anatomists into no less than ten layers, 
the principal of which are : the layer of nerve fibres, the layer 
of rods and cones, and the pigment layer. The first of these 
is but a simple expansion of the optic nerve fibres, being thick- 
est at the optic disc, where the expansion begins, and gradually 
thinning down as it approaches the ciliary processes in front. 
It lies next the internal limiting layer or surface of the retina, 
and forms the conducting layer, as that of the rods and cones 
constitutes the perceptive layer. 

14. The macula lutea, or central transparent spot of the 
retina, having in its centre a depression called the fovea 
centralis. 

15. The or a serrata, or posterior edge of the ciliary pro- 
cesses. The engraver has represented this with a regular curve 
line, whereas it should be serrated, to correspond with the name. 

16. The zonule of Zinn, or suspensory ligament of the lens. 

17. The crystalline lens, a double convex body, suspended 
from the ciliary processes immediately behind the iris. It is en- 
closed in a transparent capsule, the anterior and posterior por- 
tions of which are denominated the anterior and posterior 
capsules. The lens is transparent, laminated, and increases in 
density or hardness towards the centre, or nucleus, where it has 
about the consistency of soft wax. At birth it is perfectly 
colorless, but as age advances it acquires more or less of an 
amber tint, impairing to some extent its transparency. 

18. Ciliary processes. The ciliary processes are some 
seventy-five or eighty in number, and constitute what is known 
as the ciliary body. This is composed chiefly of the ciliary 
muscle, covered by the choroid and pigment layer. (See 
choroid.) The ciliary muscle is composed of two sets of fibres ; 



DISEASES OF THE EYE. 



07 



an anterior set which are circular, and a posterior which are 
radiating or meridional. 

19. The anterior chamber, or concavity, bounded by the 
cornea and iris. 

20. The posterior chamber, bounded anteriorly by the uvea, 
and posteriorly and laterally by the lens, a portion of the 
zonula, and the ciliary processes. The anterior and posterior 
chambers communicate by the pupil ; and are filled with a 
transparent watery fluid, called the aqueous humor, which 
readily escapes whenever the cornea is punctured, but is rapidly 
restored by secretion. 

21. The vitreous humor. This is a transparent, jelly-like 
substance, containing neither vessels nor nerves, which occupies 
the entire cavity of the retina. So far as simple appearance is 
concerned, it bears a striking resemblance to glass, whence it 
derives its name. It consists of a loose cellular texture, con- 
taining water in its interstices, the latter constituting some 
ninety-eight per cent, of its bulk. The membrane inclosing the 
vitreous body, and which is but an external condensation of the 
cellular mesh-work, is called the hyaloid membrane, so named 
by its discoverer, Fallopius. 

Lachrymal organs.* 
a, a, Puncta lachry7nalia y or 
openings of the lachrymal 
canals, in the lids. 

a, b y c t d, Lachrymal canals- 

b, b. Blind dilatations, or 
small culs-de-sac, at the orbital 
extremities of the lachrymal 
canals, where they turn inward 
to the lachrymal sac. 

e > fy g- Lachrymal sac. 




THE LACHRYMAL APPARATUS.. 



* After Sommering;. 



108 PRACTICE OF MEDICINE. 

e. The blind end of the lachrymal sac. 

g. Termination of the lachrymal sac, at which point there 
is a slight contraction which serves to distinguish between the 
sac and duct. 

h, i. The ductus ad nasum, or nasal duct. 

i. Opening of the nasal duct into the nose. 

k, I. Lachrymal gland. This is a small conglomerate 
gland situated just within the orbit, near the external angular 
process of the frontal bone. It communicates with the surface 
of the conjunctiva by means of seven or eight small excretory 
ducts, which open just above the external angle of the eye. 



DIV. I.— OPHTHALMIC INFLAMMATION. 

ART. I. — CONJUNCTIVITIS. 

Of the various forms of ophthalmic inflammation, we shall 
first describe Conjunctivitis, as that is not only the most fre- 
quent, but also the most important affection of the eye which 
the busy practitioner is called upon to treat. It is referred to 
under different names — Ophthalmia, Ophthalmitis, Conjunc- 
tivitis, etc., the first of which is the most common, the last the 
most correct. As the name implies, it is simply an inflammation 
of the conjunctival mucous membrane. This membrane is not 
only the most exposed to atmospheric influences, but also to 
direct external injuries, to irritations arising from the pressure 
of dust, cinders, and other extraneous substances in the eye, to 
inverted or misdirected cilia, and to tumors, changes in the lids, 
etc. ; all of which excite more or less inflammation of the con- 
junctiva. It may also arise indirectly from scrofulous, syphi- 
litic, or other unhealthy states of the constitution, or as a con- 
sequence of other inflammations, either simple or specific, in 
other organs or in other parts of the same organ. The simple 
form, conjunctivitis simplex, does not differ in any essential par- 
ticular from the catarrhal, so that it is unnecessary to describe 
it separately. The treatment, also, is similar, the special indi- 
cations depending chiefly upon the intensity of the inflammation ; 
these, in severe cases of simple conjunctivitis, being identical 
with those of the milder varieties of catarrhal ophthalmia. 



DISEASES OF THE EYE. 



I09 



FIG 3. 




I.-CATAEEHAL CONJUNCTIVITIS. 

CATARRHAL OPHTHALMIA; MUCOUS OPHTHALMIA. 

This is a simple inflammation of 
the conjunctiva, resulting from ex- 
posure to cold and damp. When 
the inflammatory process extends 
to the sclera, catarrhal conjunc- 
tivitis becomes either catarrJw- 
■rheumatic or catarrho-arthritic con- 
junctivitis ; and when it involves 
the lids, the affection is called 
blepharoconjunctivitis, or simply 

CATARRHAL CONJUNCTIVITIS. bUfkaHHS. 

Symptoms. — Dryness, itching, smarting and stiffness, with 
more or less redness, lachrymation, sensitiveness to light, and a 
feeling as though sand or some other foreign object had gotten 
into the eye. Sometimes this is really the case, even in catarrhal 
conjunctivitis, but it is much more apt to occur in the simple 
form of the affection, since it is in that manner that simple con- 
junctivitis is generally exdted. The symptom in question is 
generally due to the roughness of the conjunctival surface, 
caused by the enlarged and tortuous vessels which characterize 
the inflammation. Vision is often impaired, especially towards 
evening, on account of the abundance of mucus secreted at 
that time and deposited upon the cornea. The palpebral con- 
conjunctiva is of a bright vermilion hue, frequently flecked with 
slightly ecchymosed patches of a deeper color, and is sometimes 
so much increased in extent by relaxation, especially the great 
fold of the membrane, as occasionally to be twice its usual 
volume. In some cases, slightly diaphanous granulations, of a 
lighter color than the general surface, may be perceived upon 
the general surface, particularly of the upper lid.* Sometimes 

*This is agreeable to most authorities, and is undoubtedly true of the chronic variety, 
in which alone granulations form a prominent feature; but in the more simple subacute 
forms, I have generally found them to be most conspicuous upon the lower lid, or rather 
in the conjunctival folds between the lid and the globe, and such also appears to have 
been the experience of Eble. 



110 PRACTICE OF MEDICINE. 

also little vesicles, or pustules, consisting of slight elevations of 
the mucous membrane, and containing a serous fluid,* are situ- 
ated about the margin of the cornea. The eyelids generally 
participate more or less in the inflammation, whenever the con- 
junctivitis is of an active character. 

Diagnosis. — The vessels of the occular conjunctiva have a 
more or less regular distribution (See Fig. j.) ; their trunks are 
turned towards the circumference of the globe, from which they 
run forwards in a slightly tortuous, but nearly parallel course, 
subdividing and inosculating as they approach the cornea, and 
terminating in very fine points at the distance of about two 
lines from the outer edge of the cornea, leaving a space around 
it in the form of a band which is free from redness. The dis- 
tended vessels are quite superficial, and may easily be displaced 
by moving the lids. This form of inflammation seldom causes 
much swelling of the mucous membrane, and is not to be com- 
pared with the chemosis associated with the more acute inflam- 
mations of the conjunctiva. In addition to these diagnostic 
signs, other mucous surfaces suffer when the conjunctivitis is 
severe, producing more or less coryza, headache, and catarrhal 
fever. The symptoms, both local and general, remit in the 
morning, and undergo exacerbation at night. 

Prognosis. — Catarrhal conjunctivitis if properly treated 
undergoes resolution, and is therefore, generally speaking, free 
from danger ; but if violent, and especially if wholly neglected, 
or improperly treated, it may extend to the cornea and sclera, 
producing opacity and ulceration of the former, granulation 
and ulceration of the conjunctiva, and other serious conse- 
quences. 

ETIOLOGY. — Cold and damp are the chief exciting causes 
of catarrhal ophthalmia as they are of catarrhal affections 
in general. Great and rapid atmospheric changes, especially 
from heat to cold, often produce an attack ; so also do cold 



*And therefore not true pustules, though frequently so called. 



DISEASES OF THE EYE. Ill 

winds, especially when combined with rain or snow. Changes 
of clothing, especially such as favor a chill of the surface, 
are capable of producing it, particularly if the head itself is 
exposed. Getting wet, either partially or generally, expo- 
sure to drafts of air, and whatever causes a chill of the body, 
may all give rise to it ; it is also sometimes caused, appar- 
ently, by certain atmospheric influences, the nature of which 
has never been satisfactorily explained. 

Treatment. — The proper treatment for catarrhal con- 
junctivitis is that which is best adapted to catarrhal inflamma- 
tions in general, and particularly to coryza, with which it is fre- 
quently associated. Hence the principal remedies are : 

Aconite* especially at the beginning of the attack. This 
remedy alone will frequently allay the inflammation, provided 
no untoward complications exist. 

Apis mel. — This remedy is often associated with Aconite, 
especially in the first stage, and, not unfrequently, with great 
apparent benefit. 

Belladonna* — This medicine is best adapted to the more 
violent forms of catarrhal conjunctivitis, particularly when there 
exists considerable sensitiveness to light. 

Euphorbinm. — This is often a very efficient remedy in 
violent forms of the disorder ; also in chronic catarrhal con- 
ditions, with dryness and itching of the lids and canthi. 

Euphrasia is an excellent medicine, similar in its action to 
Belladonna, and especially adapted to cases complicated with 
coryza, or with copious mucous discharges from the nasal pas- 
sages. It also generally has an excellent effect when applied 
locally in suitable cases. 

Hepar Sulph. — This remedy is best adapted to the sub- 
acute forms of catarrhal inflammations ; also in the acute after 
Aconite and Belladonna, particularly the latter. 

Mercurius.. — This is one of our most efficient remedies in 



*See Am. Horn. Obs., vol. iv., p. 440, (sub-acute; A, 1-10,) 



112 PRACTICE OF MEDICINE. 

obstinate cases, especially when associated with a general 
catarrhal condition of the system. 

Rhus Tox. has also been found useful in bad cases of 
catarrhal ophthalmia, attended with more or less cedematous 
swelling of the conjunctiva. 

The chief remedies for the more chronic forms of catarrhal 
conjunctivitis are : 

A rsenicum, especially when there is ulceration of the cornea 
and the margin of the lids ; also when there is oedema, lachry- 
mation, and nightly agglutination. 

Calcarea. — This remedy is particularly useful in cases 
similar to the above, and of long standing, especially if aggra- 
vated by reading or sewing. 

Hydrastis Canaden. — This medicine may be used to ad- 
vantage, both locally and generally, in chronic catarrhal con- 
junctivitis, especially when attended with ulceration ; it is also, 
like Hepar Sulph., frequently useful in the acute and sub-acute 
forms. 

Iodinm. — This remedy is suitable to obstinate cases occur- 
ring in lymphatic constitutions, and in which there is more or 
less redness and swelling of the eyelids, with nightly aggluti- 
nation. 

Phosphorus. — In cases similar to the above, associated with 
coryza, or with a more general catarrhal condition of the system. 

Staphysagria. — This medicine is well adapted to cases 
which have become complicated with inflammation of the lids, 
especially when the meibomian glands are implicated. 

Sulphur. — This remedy is suitable to almost every form of 
chronic catarrhal inflammation, especially when attended with 
ulcerations of the margins of the lids, with swelling of the con- 
junctiva or with opacity or ulceration of the cornea. 

Thuja.— This remedy is found useful in the most violent 
forms of chronic catarrhal conjunctivitis, attended with thicken- 
ing and granulation of the lids. See Chronic Purulent Con- 
junctivitis •, § 2 (2). 



DISEASES OF THE EYE. 1 13 

Although the above list of remedies is amply sufficient for 
the successful treatment of every variety of catarrhal conjunc- 
tivitis, additional remedies, together with their symptomatic in- 
dications, will be given after the other forms of ophthalmia have 
been described. See Tables XIV. and XV.; also Therapeutic 
Indications at the end of the Section on Ophthalmic Diseases. 

Local Treatment. — Topical treatment, under homoe- 
opathic medication, is seldom required in either the acute or 
sub-acute forms of catarrhal conjunctivitis. If, however, owing 
to constitutional weakness, or other causes, the inflammation, in 
spite of the indicated constitutional remedies, runs very high, 
and especially if there be much chemosis, or swelling, cold com- 
presses will generally give great relief, and aid materially in 
bringing about speedy resolution. Irritating collyria, however, 
are never admissible during this stage. It is not until the in- 
flammation has been somewhat subdued, or else is disposed to 
linger, or become purulent, that collyria are beneficial ; and 
then they should be of the most simple character, such as a 
solution of one grain of nitrate of silver, one or two of the 
sulphate of copper or zinc, two or three of alum, the same 
quantity of the acetate of zinc, or five or six grains of borax, 
to the ounce of distilled water. These should be interchanged 
from time to time, using such only as are found to be most 
beneficial and agreeable to the patient, and either discontinued 
altogether or conjoined with the use of the cold compress, 
whenever active inflammatory symptoms supervene. If the 
collyrium, however weak it may be (and it should never be very 
strong in the early stages of the disease), causes much pain, it 
should either be abandoned, or greatly reduced in strength, as 

experience shows that such washes generally do more harm than 
good under such circumstances. By carefully adapting them, 
however, to the requirements of each particular case, they may 
be made to contribute to both the comfort and benefit of the 
patient. If the inflammation prove obstinate, and especially if 
the discharge assume a purulent character, the case should be 
treated as directed in the following section. 

is 



114 PRACTICE OF MEDICINE. 



2 -PURULENT CONJUNCTIVITIS. 

CONJUNCTIVITIS BLENNORRHOICA ; PURULENT OPHTHALMIA. 
We propose to describe under this head the varieties of 
conjunctival ophthalmia originating in the mucous membrane of 
the eye, and oft^n confined to it, characterized by an increased 
secretion of a purulent or puriform character. They are : 

a. Conjunctivitis neonatorum, or purulent ophthalmia of 
newly born infants. 

b. Conjunctivitis purulenta, or purulent ophthalmia in the 
adult. 

c. Conjunctivitis gonorrhoica, or acute gonorrhceal ophthal- 
mia. 

These varieties of conjunctivitis are strikingly similar in 
their symptoms, course and terminations, are all very destruc- 
tive to the integrity of the organ, and are chiefly distinguishable 
from each other by the age of the patient, or by the nature of 
the exciting cause. 



A— Conjunctivitis Neonatorum. 

PURULENT OPHTHALMIA OF INFANTS. 

Symptoms. — This form of conjunctivitis generally sets in 
about three days after birth, but it sometimes begins at an 
earlier and sometimes at a later period. At first it is limited to 
the palpebral conjunctiva, which is red and velvety ; the edges 
of the lids, also, are somewhat red, particularly at the corners, 
where they adhere slightly to each other, the adhesion arising 
from their being kept closed in consequence of pain experienced 
on exposure to light, and to the secretion by the inflamed mem- 
brane of a small quantity of white mucus, which may be seen 



PRACTICE OF MEDICINE. 115 

on everting the lower lid. This blepharo-blennorrhcea, or bleph- 
aritis, as it is termed, constitutes what is called the first stage. 

The second stage is marked by the extension of the disease 
to the ocular conjunctiva, the redness and inflammation being 
greatly increased, and the inflamed membrane pouring out a 
copious puriform secretion, which causes adhesion of the palpre- 
bal edges, and the accumulation between the swollen and 
inflamed lids of more or less of the purulent matter. In this 
stage, there is always considerable tumefaction both of the lids 
and conjunctiva, the loose folds of the latter being distended 
into fiery rolls, having a finely granulated or villous appearance, 
and producing in many cases temporary ectropium of one or 
both of the lids. Photophobia is always great, and generally 
extreme, the child contracting its brow, and resisting as much 
as possible every attempt at exposure to the light. Whenever 
the lids are separated, especially in the morning, a profuse 
purulent discharge generally gushes out, and pours over the 
face of the child ; and in all cases the puriform secretion is 
sufficiently abundant to agglutinate the lids, and, when sepa- 
rated, to conceal from view the inflamed surfaces. The dis- 
charge is of different degrees of consistency, and of various 
shades of color, being generally of a purulent or muco-purulent 
character, but sometimes ichorous or sanious and even bloody. 

The third stage stage is characterized by a gradual sub- 
sidence of the inflammation ; the redness and tumefaction abate ; 
the secretion is not only diminished in quantity, but altered in 
quality, becoming bland and muculent; the photophobia sub- 
sides, so that the child will even open its eyes when the light is 
subdued; and the temporary ectropium, resulting from the 
eversion and strangulation of the lids, disappears, so that the 
eye can now be carefully examined. 

RESULTS. — Opacity, ulceration and more or less sloughing 
of the cornea, as well as adhesion of the iris to its inflamed or 
ulcerated surface, may all occur in the second stage of the com- 



Il6 CONJUNCTIVITIS NEONATORUM. 

plaint. When the whole cornea sloughs and the humors escape, 
the eye shrinks greatly in size, appearing like a flattened tubercle 
at the bottom of the orbit, when the humors are retained, the 
front of the globe only is flattened. When, in consequence of 
extensive sloughing of the cornea, the iris prolapses and becomes 
adherent, staphyloma, either partial or general, commonly super- 
venes; sometimes, however, the tumor thus formed gradually 
diminishes until only a small brown point remains in the cornea, 
impairing the vision more or less, according to its situation and 
extent. The cicatrices *left after healing of the corneal ulcera- 
tions are opaque, and consequently interfere more or less with 
vision. Permanent opacity of the cornea, {leucoma albugo,) 
resulting from a greater or less amount of interstitial deposition, 
may be either partial or general; in such cases, of course, vision 
is more or less permanently impaired ; but when the opacity is 
superficial, or results from a slight degree only of interstitial 
deposition, the effusion will ultimately be absorbed, and the 
transparency of the cornea fully restored. 

Prognosis. — When the disease is severe, neglected, or 
badly treated, the danger to the eye becomes very great, and 
vision is apt to be permanently injured. On the contrary, if 
the case be taken in hand early, before the cornea becomes 
seriously affected, the inflammation can almost always be sub- 
dued in time to avert the dangers to which this form of con- 
junctivitis is subject. Indeed, if the cornea remains clear, 
even if the inflammation has extended to the ocular conjunc- 
tiva, but little risk is incurred, provided the most prompt and 
efficient means are employed. But if extensive ulceration or 
sloughing of the cornea has occurred, or if inflammation has 
extended to the deeper structures of the eye, producing adhe- 
sion of the iris, {synechia anterior^) or impairing the transparency 
of the humors, the loss of vision will be unavoidable. 

ETIOLOGY. — Purulent conjunctivitis of new-born infants has 
been proven in many instances to be contagious ; and the gen- 



PRACTICE OF MEDICINE. 117 

eral appearance of the disease on the second or third day after 
birth, taken in connection with the fact that, in a large propor- 
tion of cases, the mothers have been observed to have a morbid 
vaginal discharge, such as leucorrhoea or gonorrhoea, renders 
the received notion of its contagious origin from contact of these 
morbid secretions, highly probable, to say the least. On the 
other hand, conjunctivitis neonatorum frequently attacks the 
children of healthy mothers, or, at least, of such as appear to 
be quite healthy, so that the question as to the contagious 
origin of the complaint still remains to some extent unsettled.* 
Whether contagious or non-contagious, however, one thing is 
certain, namely, that those influences that excite other forms of 
conjunctivitis are capable of producing this ; thus it is found to 
be most frequent and destructive among weakly children, and 
such as are inadequately and improperly nourished, clothed and 
housed ; also, that it is more prevalent and destructive where 
large numbers are collected together, as in foundling hospitals, 
especially those which admit children of the lowest class, the 
mothers of which are frequently affected with leucorrhceal or 
other vaginal discharges, and whose infants are often puny, 
premature and badly nourished. 

Treatment. — In order to avoid unnecessary repetition, 
we shall mention in this place only a few of the leading medi- 
cines adapted to this variety of ophthalmic inflammation, refer- 
ring to Tables XIV and XV, and also to the Therapeutic 
Indications at the end of the Section on Ophthalmic 
Diseases, for such additional remedies as may be required in 
exceptional cases. 

Aconite. — This medicine appears to be incapable of causing 
a true inflammatory exudation of plastic lymph or pus, and is 
therefore of no value in this form of inflammation, except 

*It is true, the most recent authorities regard every form of purulent conjunctivitis, even the 
catarrhal, as somewhat contagious, and this is no doubt true ; but our own experience, no les 
than that of many others, to say nothing of the general history of the disease, is not such as to 
warrant us in giving an unqualified opinion on the subject in question. 



Il8 CONJUNCTIVITIS NEONATORUM. 

during the first stage of the complaint, and even then it will be 
most useful if given in alternation with Argent, nit, or Bella- 
donna. 

Argentum nit. — This remedy enjoys the reputation of being 
a specific for this form of conjunctivitis ; it is well to alternate 
it with other medicines whenever special symptoms demand a 
change of remedies. 

Belladonna. — This remedy is well adapted to the first stage 
of conjunctivitis neonatorum, especially in the less acute grades 
of the disease ; its use, however, should not be persisted in after 
the secretion has become thick and copious, but the practitioner 
will do well, as a general rule, to resort at once to 

Bryonia: — This medicine is adapted to the second stage, 
when the conjunctiva has become more or less infiltrated, the 
secretion being thick and slimy and the lids agglutinated ; but, 
unless improvement rapidly follows, resort should be had to 

Hepar Sulph., or to the Muriate of Hydrastia, either singly, 
or in alternation with Bryonia or 

Mercurius. — This is perhaps the most reliable remedy after 
the second stage has become fully established and plastic exu- 
dation has taken place, especially if pustules or ulcers have 
already formed on the cornea. 

Rhus tox. — This medicine is also well adapted to the second 
stage of the disorder, especially when there is very great swell- 
ing of the lids and conjunctiva, with redness and hard swelling 
of the tarsal edges. 

Thuja. — This remedy, which is better adapted to severe 
forms of catarrhal conjunctivitis, has been recommended chiefly 
on theoretical grounds ; yet it has been proven to be of consid- 
erable value in many cases, especially when there is very 
high inflammation, with great redness and swelling of the lids 
and ulcerations of the tarsi and cornea. 

Auxiliary Treatment. — Great care should be taken to 
cleanse the eyes, as often as may be needed, with warm milk 



PRACTICE OF MEDICINE. 119 

and water, by means of fine old linen rags, never using the 
same piece twice, and never opening the lids without first soak- 
ing them until the dried and glutinous matter is entirely 
removed. A light linen compress, saturated with a solution of 
Belladonna or Thuja, of the strength of fifteen or twenty drops 
of the mother tincture to the glass of water, and frequently 
changed, may be used to advantage in the first and second 
stages respectively ; and a solution of A rgentum Nitratum, one 
grain to the ounce of distilled water, and kept in the dark, may 
be dropped into the eye, or applied to diseased surfaces, every 
six hours during the suppurative stage, by means of a camel's 
hair pencil, being careful to cleanse the pencil with warm water 
every time it is used. This application not only destroys the 
contagious character of the secretion, but acts favorably upon 
the inflammation, by limiting the exudative process and pro- 
moting the absorption of the exudation ; and, if carefully and 
timely applied, it will insure resolution of the inflammation, by 
preventing disorganization of the ocular structures and conse- 
quent loss of vision. 

Diet and Regimen. — From what has been said respect- 
ing the nature and causes of this disease, it is evident that the 
nutrition of the infant is a matter of the highest importance ;* 
and for this purpose, healthy maternal breast-milk should, if 
possible, be obtained. If, however, the babe must be fed with 
artificial food, well-cooked oat-meal, prepared with half water 
and half milk, and strained, will, as a general rule, be found to 
be the best substitute. Due attention to cleanliness, the use of 
a proper amount of warm, clean clothing, and a plentiful supply 
of pure air, are matters also which the practitioner should be 
careful to enjoin. 



* To those practitioners who are accustomed in this complaint to rely wholly on medi- 
cation, these directions may appear both antiquated and unnecessary; but an experience of 
many years in its treatment, and the disastrous results which in many cases we have 
observed to follow the neglect of suitable hygienic measures, especially in public institutions, 
not only authorize, but demand, we think, their observance in all cases. 



120 PRACTICE OF MEDICINE. 

B— Conjunctivitis Punilenta. 

PURULENT OPHTHALMIA OF THE ADULT ; MILITARY OR 
CONTAGIOUS OPHTHALMIA. 

This form of conjunctivitis is of different degrees of severity, 
according as it occurs in civil life and under favorable circum- 
stances, or in the army, in over- crowded barracks, hospitals, etc. 
In the former case, it is generally a comparatively mild affec- 
tion, differing in no respect from the milder form of conjuncti- 
vitis neonatorum just described, except as modified by age and 
other accidental circumstances. Indeed, there is reason to 
believe that in some instances it is nothing more than a severer 
and more dangerous form of the catarrhal. In the latter case, 
however, owing doubtless for the most part to exposure, a scor-' 
butic state of the system and want of cleanliness, it has proven 
exceedingly destructive, no less than eleven hundred cases of 
blindness having occurred in the Prussian army out of thirty 
thousand attacked. Sometimes, also, the ravages of the disease 
are alarming even in civil life, as when it breaks out in asylums 
and large schools, or when, through neglect of sanitary precau- 
tions, or the non-observance of suitable hygienic measures, it 
becomes epidemic. The latter constitutes what is generally 
known as 

(I.) — ACUTE PURULENT CONJUNCTIVITIS. 

Symptoms. — As in ophthalmia neonatorum, the redness 
and inflammation are at first confined to the palpebral conjunc- 
tiva ; there is also more or less lachrymation, stiffness of the lids, 
and accumulation of whitish mucus on the inflamed membrane. 
This is the first stage, or blepharo blennorrhea. The inflamma- 
tion soon extends to the conjunctiva oculi, producing great 
redness and swelling of the affected membrane, and copious 
discharge. At first there is simple stiffness of the globe and 
lids, but this is soon followed by a feeling as though sand or 
cinders were in the eye. The lachrymation of the first stage is 
succeeded by a puriform discharge, so copious as to frequently 



DISEASES OF THE EYE. 



121 




fig. 4- overflow the lids and face. Che- 

mosis, from swelling of the ocular 
conjunctiva, becomes so great as 
frequently to overlap and nearly 
cover the cornea, forming with the 
swollen membrane of the lids, two 
large pinkish rolls or protuberances, 
which so effectually close the eye 
as to render a satisfactory view of 
the cornea quite impossible. When the inflammation extends 
to the sclera, the pain is greatly augmented, becoming at times 
almost intolerable ; the constitution also sympathises with the 
affection, producing a feverish state of the system, attended by 
headache, throbbing in the temples, loss of appetite, etc. The 
vascular exitement and suffering remit or abate from time to 
time, generally in the morning, and sometimes they become 
distinctly periodical. This is the second stage, commonly called 
ophthalmo-blennorrhoea. The third stage is marked, by a general 
subsidence of the foregoing symptoms ; the pain, swelling and 
discharge diminish, leaving however for a considerable period 
more or less eversion of one or both of the lids. 

Results. — Among the effects sometimes resulting from 
acute attacks of purulent ophthalmia, we have opacity, rupture, 
sloughing, suppuration and ulceration of the cornea, interstitial 
deposition into and between its laminae, prolapsion and adhesion 
of the iris, vascularity, thickening and separation of the mucous 
membrane covering the cornea, staphyloma, ectropium, en- 
tropium, and enlargement or collapse of the globe. Even when 
no such effects follow the inflammation, a certain degree of 
impaired vision (amblyopia) sometimes remains, owing to - 
changes in the lens, choroid coat, vitreous humor, and vessels of \ 
the orbit and brain. 

Diagnosis. — The violence of the disease, the purulent char- 



16 



122 PRACTICE OF MEDICINE. 

acter of the secretion, and the changes above-mentioned, 
especially the chemosis, which, as a dropsy of the conjunctiva, 
is not to be compared with the swelling of the conjunctiva in 
catarrhal ophthalmia, will serve to distinguish it from the latter, 
with which alone it is liable to be confounded. Severe cases of 
catarrhal ophthalmia, attended by puriform secretion, some- 
times bear a close resemblance to this disorder, and, as already 
stated, may perhaps be properly regarded as mild cases of the 
disease ; but the fact that the inflammatory process commonly 
affects the whole conjunctival surface at once, instead of being 
confined for a time to the palpebral conjunctiva alone, as in 
purulent ophthalmia, will, in connection with the history and 
progress of the case, generally serve to establish a satisfactory 
diagnosis between them.* 

PROGNOSIS. — Notwithstanding the formidable character of 
the inflammation, if the cornea be unaffected, suitable treat- 
ment will generally arrest the disorder ; but if the cornea, and 
especially the globe, be involved in the inflammation, the event 
is more or less doubtful. Interstitial deposition, suppuration, 
and even ulceration, unless considerable, and occurring in a bad 
state of the system, do not necessarily involve the loss of vision, 
much depending, of course, on the extent and situation of the 
changes ; if the centre of the cornea, or any considerable por- 
tion of it, remains clear, the sight is not likely to be greatly im- 
paired. The general prognosis depends, of course, on the more 
or less rapid progress of the inflammation ; the more rapidly it 
passes through its several stages, the more danger we shall have 
to fear. Whenever the true nature of the exciting cause can be 
determined, we shall have still surer ground upon which to base 
the probable results. Thus, if the blenorrhcea depends upon 



* The following is the diagnosis of Prof. Arlt, Vienna : " The upper lid is to be everted, 
and if the conjuctiva is sufficiently transparent for us to see the lines of the meibomian glands 
running toward the eye, of the tarsus, we have a catarrh; if the infiltration is so great as to 
hide these glands, we have no longer a catarrh, but either a purulent or some graver form of 
ophthalmia."~ANGELL on Diseases of the Eye, p, 28. 



PURULENT CONJUNCTIVITIS. 1 23 

infection, forty-eight, or even thirty-six hours may be sufficient 
to produce irreparable injury to the cornea, and consequently 
to vision. 

ETIOLOGY. — Severe catarrhal and mild purulent ophthalmia 
are so closely related, that it cannot be positively denied tftat 
the latter may sometimes originate in the same causes that give 
rise to the former ; but it is generally admitted to be of an in- 
fectious origin and nature; indeed, in most cases it can be traced 
directly to some contagious or blenorrhceic secretion, emanating 
either from the eyes or from the genital organs. The contagion 
is promoted, of course, by everything which tends to favor it, 
such as the crowding together of large numbers in the same 
apartment, thus accounting for its comparatively frequent oc- 
currence in asylums and large schools, and in army hospitals. 
The same circumstances, likewise, superadded to exposure, 
want of cleanliness, and a scorbutic or psoric condition of the 
system, greatly facilitate the spread of the contagion, and hence 
the fearful ravages which the disease sometimes makes in the 
army. 

In proof of its contagiousness, it is only necessary to cite 
the fact that it has frequently been communicated by direct in- 
oculation, not only accidentally in persons, but intentionally in 
animals, the disease having been repeatedly produced in dogs 
and cats by the application of the purulent secretion to their 
eyes. Additional confirmation is found in the fact that, being 
endemic in Egypt, it was first brought to Europe by the English 
and French armies — whence the name of Egyptian Ophthalmia, 
by which it is sometimes known — and from this source its pro- 
gress was traced from the infected to the uninfected, until the 
Europeon surgeons were, with but few exceptions, cgnvinced of 
its contagious character. On the other hand, as Lawrence 
observes, " this notion of a specific contagion, imported from 
Egypt, originated in Europe, never having occurred in the sup- 
posed birth-place of the virus. Assalini, and the other medical 



124 PRACTICE OF MEDICINE. 

observers who actually witnessed the affection in Egypt, refer 
it to the ordinary causes of ophthalmic disease." In confirma- 
tion of the latter opinion, it may be stated, that where collec- 
tions of individuals affected by it have been separated, the 
disease, instead of being propagated to others, generally abates. 
The only rational conclusion, therefore, that we can come to on 
this subject, is, that as a general rule, when the disease breaks 
out in over-crowded, filthy, and disease-producing situations, 
the malady becomes highly contagious and virulent ; while on 
the other hand, in situations and under circumstances favorable 
to health, it soon undergoes amelioration, generally losing, to a 
great extent, at least, its contagious character, and becoming 
milder and more manageable.* This will satisfactorily account 
for the milder form which the disease often assumes, not only 
in civil life, but also in the army, whenever suitable hygienic 
regulations are observed. 

Treatment. — This should be similar to that recommended 
for ophthalmia neonatorum, only, as the inflammation is gener- 
ally of a higher grade, the treatment should, if possible, be still 
more energetic. As the same indications exist, the same reme- 
dies will be found applicable, and it will therefore be uneces- 
sary to repeat them here. See Treatment of Conjunctivitis 
Neonatorum, and consult also the remedies mentioned in Table 
XIV, at the end of the section on Ophthalmic Diseases. 

Local Treatment. — Most authors recommend ice and 
ice water compresses for external use, and when well-borne and 
regularly and judiciously applied, they are found to be a very 
efficient means of subduing the inflammation, but it should be 
remembered that such applications are extremely hazardous in 
unreliable* and inexperienced hands. We have often obtained 
much better results from water of a moderate coldness only, 
applied constantly by means of light linen rags, frequently 
renewed, taking care to cleanse the eyes from time to time with 



* See Am. Horn. Obs., vol. il, p. 309, et seq. 



PURULENT CONJUNCTIONS. 125 

fresh portions of the same. Sometimes even this degree of 
cold cannot be borne without great pain, in which case it should 
be used tepid, or else omitted altogether, except for purposes of 
ablution. 

After the redness and swelling of the inflamed membrane 
have somewhat subsided, and the pain and soreness have 
mostly disappeared, astringent washes, composed of such sub- 
stances as we have already mentioned, will prove most beneficial, 
especially when used in conjunction or alternation with a solu- 
tion of Argentum Nitratum, of the strength of from three to 
eight grains to the ounce, according to the severity of the case, 
applied by means of a camel's hair pencil, in the manner 
recommended for the purulent conjunctivitis of infants ; 
remembering always to rinse the lids immediately after making 
the application, and not to repeat it oftener than twice a day 
If the caustic applications are made prematurely, before the 
inflammation is sufficiently reduced, they will aggravate the 
complaint, and should at one be suspended, until, by the use of 
Aconite internally and cold compresses externally, the inflam- 
mation is so far lessened that they can be resumed with benefit. 

DIET AND REGIMEN. — If the general*health of the patient 
is good, the diet should be very light, consisting only of farina- 
ceous food, wholesome fruits, and light, unstimulating drinks ; 
but if weak and emaciated, and especially if there is a scroful- 
ous or scorbutic state of the system, the diet should be liberal 
and nutritious. Should the case linger from any cause, as it is 
frequently apt to do in a depraved state of the constitution, and 
especially if the loss of vision be threatened by progressive 
ulceration of the cornea, such articles as milk, eggs and beef 
should be prescribed, and if necessary even a moderate amount 
of port wine should be allowed ; since, in these cases, notwith- 
standing the inflammation, the danger to the integrity of the 
organ arises rather from under than from over stimulation. But 
before resorting to even the mildest stimulative measures, the 
practitioner should be certain that he has correctly interpreted 
the constitutional state ; otherwise irreparable mischief will be 
the consequence. 




126 PRACTICE OF MEDICINE. 

GEANULAR CONJUNCTIVITIS. 

CHRONIC PURULENT OPHTHALMIA ; TRACHOMA. 

Fig - 5 - This much the most 

commen form of Puru- 
lent Ophthalmia, espec- 
ially in civil life. It is 
distinguishable from the 
acute form just describ- 
ed, chiefly by its being 
confined, except in very 
rare instances, to the 
palpebral conjunctivia ; 

GRANULAR CONJUNCTIVITIS. , ,, 

by its generally running 
a comparatively mild and very chronic course; and by a gradu- 
al change of the mucous lining of the lids, especially of the 
lower, which, after the lapse of several weeks or months, are, so 
to speak, over-run with patches of minute fleshy growths, or 
vegetations, called " granulations," which give to the affected 
membrane a rough, mulberry like appearance, (trachoma)) The 
size and color of the granulations are generally proportioned to 
the intensity of the inflammation ; when the conjunctivitis is 
most intense, they are commonly of a deep red or garnet color, 
and of a rough, warty, or condylomatous appearance ; but 
when the inflammation is less violent the palpebral conjunctiva 
is paler, and appears as if sprinkled with dust or fine sand. At 
first the granulations are soft and tender, and bleed easily ; 
afterwards they become more and more indurated, and give to 
the conjunctiva a somewhat seamed or cracked appearance.* 

SYMPTOMS. — The disease often sets in so gradually as 
scarcely to attract attention. Commencing with the symptoms 



* It is important to distinguish between granulations , properly so called, and enlarged 
papillce. The latter ordinarily accompany the former, but are more superficial ; granulations, 
proper are an inflammatory product, appearing, even before changing into cacatricial tissue, 
as distinct formations, like grains of sand, lying immediately under the conjunctiva. 



PRACTICE OF MEDICINE. 1 27 

of catarrhal ophthalmia, the patient experiences more or less 
uneasiness in the eye, attended with a feeling of heat or burn- 
ing, especially of the tarsal edges, which exhibit more or less 
redness ; sometimes the inflammation is confined to the tarsal 
portion of the lids for a considerable period ; afterwards, when 
the inflammation has spread towards the globe, the patient 
complains of a feeling of dryness and roughness in the eye, as 
if caused by particles of foreign matter beneath the lids. There 
is now an increased secretion of tears and of mucus, but little or 
no pain. The disease may continue in this mild form for two 
or three weeks, and then terminate under proper treatment? 
or, in consequence of unfavorable circumstances, it may increase 
in intensity until it reaches a higher grade, the conjunctiva be- 
coming redder and more swollen, and secreting a thick, glutin- 
ous, or puriform matter. The affected membrane now takes 
on the characteristic granulated appearance ; the lids partici- 
pate in the general swelling ; and the pain becomes more con- 
siderable. This, the most inveterate form of the complaint, 
may last for several weeks or months before it terminates, eith- 
er by resolution, or, which is more common, by reaching a still 
higher degree of intensity — a grade which, like the former, it 
may assume from the beginning. This stage or degree of the 
inflammation generally supervenes suddenly on the condition 
just described ; and from its great violence may work irrepara- 
ble mischief to the organ within a few hours. The pain is now 
severe, and of a burning, aching or stabbing character ; the 
granulations become warty and luxuriant ; the lids swell enor- 
mously ; the purulent discharge becomes profuse ; and a condi- 
tion of the palpabral conjunctiva succeeds similar to what oc- 
curs in the third stage of acute purulent ophthalmia, except as 
modified by the granulated state of the lids. 

RESULTS. — The ordinary and characteristic results of 
chronic purulent ophthalmia, are such as arise from the thick- 
ening and granulation of the lids. Even after the removal of 



128 GRANULAR CONJUNCTIVITIS. 

the symptomatic affections, so long as the granulations exist 
there will remain more or less weakness of vision, arising from 
irritation, together with swelling of the eyelids, a lessening of 
the palpebral fissure, and, in some cases, more or less eversion 
of the tarsi. 

In addition to these changes, there is commonly more or 
less vascularity and opacity of the cornea, generally of its 
upper half, arising from the friction of the granulated surface of 
the conjunctiva, which is chiefly limited to the upper lid. The 
vascularity of the mucous covering of the cornea may become 
so great as to constitute what is technically termed pannus. As 
the results of severe inflammation, we may also have ulcer, 
leucoma, prolapsion and adhesion of the iris, and staphyloma. 

Prognosis. — This is generally favorable ; though there 
will always remain great liability to relapse, the weakened ves- 
sels of the conjunctiva becoming congested by very slight caus- 
es. The constitution, habits and occupation of the patient, as 
well as the state of tne weather, and other accidental circum- 
stances, will have much to do with the progress and termina- 
tion of the case. The disease which appears greatly improved 
to-day, may be greatly aggravated to-morrow. In this way 
months and even years sometimes elapse, the superficial and 
interstitial changes of the palpebral conjunctiva gradually be- 
coming greater and greater, until it is even doubtful in some 
cases whether the affected membrane can ever be fully restored 
to a healthy state. 

Etiology. — The causes of chronic purulent ophthalmia 
are the same as those which give rise to the acute form,and need 
not therefore be repeated. Less commonly, the disease suc- 
ceeds to the acute form ; the latter, owing to bad management, 
or some vice of the constitution, not undergoing complete reso- 
lution. , 

Treatment.* — As surgeon in charge of the Ophthalmic 

*See Am. Ho7n. Obs., vol. ^., p. 466. 



PRACTICE OF MEDICINE. 120, 

Department of Brown General Hospital, our experience in the 
treatment of this disease during the late war was by no means 
inconsiderable ; and as the result of that experience, and of 
over twenty years practice in civil life, we desire at the outset 
to express our emphatic disapproval, except in the inveterate 
form called trachoma ficosa, of the escharotic method of treat- 
ment. We are convinced that the indiscriminate use of power- 
ful escharotics in every form and stage of the complaint, has 
been the means of practicing, and, in many cases, of confirm- 
ing this formidable affection ; (1) by aggravating the local ex- 
citement ; (2) by increasing the tendency to relapse ; (3) by 
renewing and increasing the inflammation ; and (4) by taking 
the place of more rational and efficient treatment. So far as 
local measures are concerned, the following distinctions will be 
found to be of great practical importance : 

1. When the conjunctiva, instead of having its natural pol- 
ished surf ace, is villous or velvety, or when the gra7iulations are 
small, pale, and sand- like ; in short, when the so-called granula- 
tions are quite recent, or when they consist simply in a swollen 
or hypertrophied state of the conjunctival papillce escharotics 
are unnecessary, and generally harmful. In these cases, the ap- 
plication of cold salt-water compresses, whenever demanded by 
an increase of inflammatory action, and the employment, in the 
intervals, of mild astringent lotions, such as we have recom- 
mended for the acute form, with due attention to diet, pure air, 
and exercise, with repose and protection of the organ,* will 
generally be found to give the most prompt, marked and per- 
manent relief. 

2. When the granulations are large, flabby, and easily 
torn y the above treatment, aided by internal remedies, may still 
hold them in check, and even promote their absorption ; if not, 



* Dr. Dobrowelski, of St. Petersburg, in Annates a Oculistique, pointr out the com- 
parative value of blue, and grey or smoked glasses as a protection against the sun's rays, 
giving the preference to the latter. See Am. Horn. Obs., vol. xi. p, 555. 



130 GRANULAR CONJUNCTIVITIS. 

it may be aided by a wash of Kali HYDRIODICUM, or by touch- 
ing them with a crystal of the Sulphate of Copper, the lat- 
ter being used only to suppress the exuberance of the granula- 
tions. 

3. When the granulations have a firm, pale, zvart-like 
appearance, and cnt like cartilage, escharotic treatment is not 
only admissable, but required. In these cases we have derived 
the greatest benefit from passing a pencil of Argent. CUM, 
CALCE freely over the granulated surface, being particular be- 
fore restoring the lid to its natural position, to wash it carefully 
with water or diluted vinegar, in order to prevent any farther 
action of the escharotic. (See Fig. 5.) This application should 
never be repeated oftener than once a week, nor the sulphate of 
copper oftener than once in two, three or four days, according to 
the amount of local excitement produced by it ; remembering in 
all cases that, whenever local treatment causes any aggravation 
of the symptoms, the irritation and increased vascularity must 
be allowed to subside before repeating it ; that some cases will 
bear much stronger applications than others ; that when their 
use is attended by a sense of relief, they are always beneficial ; 
but when pain and increased vascularity are permanently ex- 
cited by them, they will always do harm, especially if too fre- 
quently applied. 

The internal remedies especially adapted to this variety of 
ophthalmic inflammation, in addition to those previously re- 
commended, are : 

Acidum nit. — This medicine is suitable for most cases of 
chronic purulent ophthalmia, especially such as are associated 
with a syphilitic or mercurial cachexia. 

Graphites. — This medicine is especially indicated when 
the edges of the lids are implicated, particularly the meibomian 
follicles. 

Iodium. — -This remedy is adapted to every stage of the 
complaint, especially when there is a psoric state of the sys- 
tem. 



PRACTICE OF MEDICINE. 13 1 

Kali Hydriodicwn. — In cases similar to those for which 
Iodium is recommended. 

Lycopodium. — Specially adapted to casrs attended with 
inflammation and ulceration of the tarsal edges. 

Mercurius. — This remedy is no less useful in the chronic 
than it is in the acute form of purulent ophthalmia. 

Sulphur. — The same remark may also be applied to this 
remedy, which is particularly adapted to the chronic form of 
the complaint, especially when attended with ulceration. 

Thuja. — We mention this remedy because it is strongly 
recommended by others, and not because we have had any 
experience with it ourselves. 

For other medicines and for fuller details, see Tablts XIV. 
and XV. ; consult, also Therapeutic Indicatioiis, at the end of 
the Section on Ophthalmic Diseases. 

Diet and Regimen. — As granular conjunctivitis is not 
pnly contagious, but, like the simple form of purulent ophthal- 
mia, is aggravated by squalor, impure air, want of cleanliness, 
improper or deficient nourishment, over-crowding of apartments, 
dampness, miasm, etc., it follows that too much attention can- 
not be paid to hygienic regulations. Indeed, experience shows 
that without due attention to these particulars, in the vast ma- 
jority of cases the improvement, if any, will be slow and un- 
satisiactory ; while on the other hand, good nutritious food, 
clean clothing and comfortable surroundings contribute in no 
small degree towards affecting a permanent cure. 



132 PRACTICE OF MEDICINE. 

C,— Conjunctivitis Gonorrhoea. 

ACUTE GONORRHCEAL OPHTHALMIA. 

This variety of conjunctivitis differs in no essential respect 
from the acute form of purulent ophthalmia already described, 
except in the specific nature of the exciting cause, and in the 
more violent and rapidly destructive character of the inflam- 
mation. Instead, therefore, of giving a detailed description of 
symptoms, which, for the most part, would be but a repetition 
of those mentioned in the preceding article, we shall content 
ourselves with merely pointing out the characteristic features 
of the disease, by way of 

DIAGNOSIS. — Gonorrhceal conjunctivitis in its most severe 
form is, with perhaps a single exception, the most rapidly de- 
structive form of purulent ophthalmia known ; frequently de- 
stroying the eye, or producing irreparable mischief to the organ, 
within a few hours. The disease, which at first is generally 
confined to the conjunctiva, producing symptoms similar to 
those of simple catarrhal or purulent ophthalmia, soon extends 
to the globe, causing the most severe and agonizing pains in 
the head and eye, accompanied with great chemosis, excessive 
photophobia, and a more or less violent febrile movement of 
the circulation. At this stage the tumefaction, both of the lids 
and the orbital conjunctiva, is extreme, completely closing the 
eye, and rendering a satisfactory view of the cornea utterly im- 
possible. As the oedema declines, one or both of the eyelids 
generally become everted, producing temporary ectropium. 

As between the highest degree of catarrhal inflammation 
and the milder form of simple purulent ophthalmia there is a 
striking resemblance in the local symptoms, so between the 
severest grade of purulent inflammation and acute gonorrhceal 
ophthalmia there is a similar resemblance. The swelling of 
the eyelids, which is always considerable, is generally more 
marked in the former, while the chemosis, or oedema of the con- 



CONJUNCTIVITIS GONORRHOICA. 1 33 

junctiva oculi, is greater in the latter; the discharge, also, is 
generally of a brighter yellow, more creamy in consistence, and 
more abundant. But the chief difference between them is that 
the latter sets in suddenly with the greatest violence, and 
proceeds with such rapidity as to terminate in a few hours or 
days, either by resolution, or what is more common, by destruc- 
tion of the organ. Again, gonorrhceal ophthalmia, with but 
few exceptions, attacks only one eye, while the purulent or con- 
tagious disease generally affects both. Finally, sloughing of the 
cornea, which is a frequent consequence of gonorrhceal inflam- 
mation; seldom or never occurs in simple purulent ophthalmia. 

RESULTS. — The immediate results, unless relieved by treat- 
ment, are : ulceration, suppuration, and more or less sloughing 
of the cornea, together with interstitial deposition into and be- 
tween its laminae. The more remote consequences are : corneal 
opacity, synechia anterior, obliteration of the pupil, staphyloma, 
and collapse of the globe. Sometimes the sloughing process, 
though general, is limited to the anterior laminae of the cornea, 
the posterior layer or membrane of the aqueous humour being 
left, so that the anterior chamber is not exposed ; in which case 
the front of the eye remains flattened, or is bulged forward by 
the protruding iris, forming what is called stapliyloma racemo- 
sum. 

Prognosis. — In a large proportion of cases, vision is either 
lost or seriously injured. Since the inflammation is not equally 
violent in all cases, the prognosis chiefly depends upon its 
comparative mildness or severity, and upon the state of the 
cornea. If the latter should be clear, the sight may be saved ; 
but if it has lost its transparency, and especially if the inflam- 
mation is of the most acute character, vision will probably be 
lost or seriously impaired. On the other hand, if the inflam- 
mation be subdued before extensive sloughing or ulceration 
occurs, the sight may be restored. 

ETIOLOGY. — This form of ophthalmic inflammation always 



134 PRACTICE OF MEDICINE. 

arises from some kind of connection, either innoculative, con- 
stitutional or metastatic, with the gonorrhceal virus. It has 
been satisfactorily proven that the application of gonorrhoeal 
matter, either from the patient's own urethra or from that of 
another person, is capable of exciting the disease in its most 
intense form. In a large proportion of cases, however, no such 
direct application of matter can be traced ; and hence the in- 
ference is unavoidable, that the disease frequently arises either 
from metastasis, as orchitis or mammitis arises from mumps, or 
else that it depends upon some peculiar condition of the con- 
stitution, in the same manner that rheumatic or arthritic oph- 
thalmia depend upon similar states of the system to those in 
which they respectively occur. Probably the latter hypothesis 
is the true one, since the urethral inflammation is never sup- 
pressed by the transference of the disease to the eye, and 
hence a true metastasis, or translation of the disease, cannot be 
said to occur in these cases. Moreover, the sudden stoppage 
of gonorrhoea by treatment is not followed by ophthalmic in- 
flammation, and hence its origin cannot be referred to the cessa- 
tion of the disease in the urethra. 

Treatment. — The treatment, both local and general, 
should be similar to that recommended for acute purulent oph- 
thalmia. The first application should consist of a saturated 
solution of Ar^entum Nitratum, which should be promptly 
applied to the diseased surfaces, in the manner described under 
the head of ophthalmia neonatorum. After the swelling and 
other effects of the application subside, the remedy should be 
repeated, observing to lessen the strength of the solution in 
proportion as the purulent discharge diminishes and the inflam- 
mation abates. As a general rule, one application per day will 
be found to suffice, provided it be sufficiently thorough. It is 
best made by everting the lids, and passing the camel's hair 
pencil, loaded with the solution, quickly over the distended 
conjunctiva, taking care to avoid touching the cornea, and to 



CONJUNCTIVITIS GONORRHOICA. 1 35 

wash the lids afterwards with tepid water before returning 
them, especially the first time the application is made. (See 

Fig- 5-) 

It should be borne in mind that the saturated solution of 
Arg. nit. here recommended is required only in the severest 
form of the disease. Many cases of gonorrhceal ophthalmia 
are so mild as to resemble the simple purulent form of conjunc- 
tivitis, and then require the same treatment. [See § B.) 

Light linen rags wet with a weak solution of Alum en or 
Muriate of Hydrastia, and frequently renewed, should be kept 
constantly applied to the affected eye. 

The internal treatment consists mainly of the following 
remedies : 

Acidum Nitricum. — This remedy is not only pathogen et- 
ically appropriate, but its use in this form of ophthalmia has 
been attended with the best results. 

Cannabis sativa. — This medicine, used low, is useful in 
every stage of the complaint, especially if there is opacity of 
the cornea, or a spasmodic pressure of the lids. 

Cantharis. — This remedy is indicated in the first stage, 
when attended with violent stinging and burning pains in the 
eye and urethra. 

Clematis — This medicine is most useful in the latter 
stages of the disorder, in cases similar to those for which Can- 
tharis is recommended. 

Hepar siilph. — This is one of our best remedies in gon- 
orrhceal ophthalmia, especially in the second and third stages. 

Mercurins. — The same remark applies to this remedy, 
Mercurius being one of the best, if not the very best remedy 
for this complaint ; it is more particularly adapted to the high- 
est state of inflammatory action. 

Additional remedies for this disorder are given in TABLES 
XIV and XV ; consult also the THERAPEUTIC INDICATIONS 
at the end of the Section on Ophthalmic Diseases. 



136 PRACTICE OF MEDICINE. 

3.— Diphtheritic Conjunctivitis. 

OPHTHALMIA DIPHTHERITICA; CONJUNCTIVIVAL CROUP. 

Closely allied in some respects to gonorrhceal conjunctivi- 
tis, but differing widely in others, is the diphtheritic. This 
disease, which seldom occurs in an idiopathic form in this 
country, and still more rarely in England and France, is not 
uncommon at Berlin and in Holland. As it appears with us 
it is most commonly associated with diphtheria in other parts, 
especially the throat, from which it is transferred either by di- 
rict contact of the irritating secretions, by sympathy, or by ex- 
tension of the disease from the nasal passages through the 
lachrymal canals.* The violence of the disease is such as to 
render it extremely dangerous to vision ; and when secondary, 
the danger is greatly increased by the liability to constitutional 
infection. The idiopathic form is characterized by the follow- 
ing 

Symptoms. — The disease sets in suddenly, with heat, pain 
and stiffness of the lids, which soon become distended, hard and 
rigid, owing to a fibrinous exudation into the conjunctival 
and episcleral tissues. There is also chemosis of the ocular 
conjunctiva, from effusion of the same fibrinous material, the 
pressure of which upon its vessels, by interfering with the cir- 
culation, gives rise to scattered points of extravasated blood. 
The discharges are at first thin, watery, and of a dirty gray 
color, or yellowish and flocculent ; afterwards they become more 
or less purulent, the pus globules being mixed with shreds of 
fibrin and disintegrated false-membrane. On examining the 
lids, the palpebral conjunctiva is found to be covered with a 
firm fibrinous membrane, which manifests a disposition to sep- 
arate at the edges, and may be easily detached with the for- 
ceps. The rapidity with which it is reproduced is truly aston- 



* See Am. Horn. Obs., vol. v, pp.70, 71. 



DIPHTHERITIC CONJUNCTIVITIS. 137 

ishing, the false-membrane sometimes attaining a thickness of 
two or three lines in the course of twenty-four hours. 

Etiology. — The exciting causes of diphtheritic conjunc- 
tivitis are doubtless the same as those which give rise to diph- 
theria in other parts ; hence it is found to prevail during the 
cold and damp seasons of the year Although adults are 
sometimes attacked, it is generally confined to children between 
two and ten years of age. According to Williams, some fam- 
ilies exhibit a constitutional predisposition to the complaint, 
the children being successively attacked on reaching a certain 
age. 

Prognosis. — The result, notwithstanding the greatest care 
and attention, is apt to be unfavorable. The chief danger lies 
in the great liability to ulceration and sloughing of the cornea 
from defective nutrition, the corrosive action of the secretions, 
and the strangulation of the implicated tissues. As an ultimate 
consequence, we sometimes have entropium, the result of con- 
traction and other structural changes in the conjunctiva and 
tarsal cartilages. 

Treatment. — The local treatment should be similar to 
that already recommended for Acute Purulent Conjunctivitis, 
using, when well borne, ice and ice-water compresses in the first 
stage, to which may be added a solution of Kal. chl., 3ij to Oj. 
In the second stage, when the discharge becomes thick and 
purulent, the escharotic treatment recommended for Gonorrhe- 
al Conjunctivitis, should be adopted. (Seethe previous section.) 
If only one eye is affected, the other should be bandaged as a 
precautionary measure. 

The internal remedies which have given the greatest satis- 
faction, and from which most benefit may be expected, are the 
following: Aconite, Kali chl., Kali bich., Phytotacco dec, during 
the first stage : Acidum nit., Argentum nit., Arsenicum, Hepar 
sulph., Mercurius ; during the purulent and ulcerative stage 
See also Tables XIV. and XV., and the Therapeutic Indica- 
tions at the end of the Section on Ophthalmic Diseases. 
18 



138 



PRACTICE OF MEDICINE. 



Diet and Regimen. — Cleanliness, which is of primary 
importance in every form of contagious ophthalmia, should be 
rigidly enforced in this, especially if but one eye is affected 
since, should both eyes become involved, the danger to vision 
will be proportionably increased. For this purpose an abund- 
ance of soft clean rags should be kept on hand, which should, 
be burned, or otherwise destroyed, as fast as used. Care 
should be taken, also, to supply the patient with clean clothes 
nutritious and easily digestible food, clean and comfortable bed- 
ding, and an abundance of fresh pure air. If, as frequently is 
the rooms are small or over-crowded, a liberal use of Carbolic 
Acid, or other suitable disinfectant, should be made, while at 
the same time the freest possible ventilation should be secured. 



4.-SCR0FUL0US CONJUNCTIVITIS. 

SCROFULOUS OR PHLYCTENULAR OPHTHALMIA. 

Fig - 6 - Scrofulous ophthalmia, as 

its name imports, is an in- 
flammation of the eye occur- 
ring in scrofulous subjects. 
Its principal seat is the con- 
junctiva oculi, but it also af- 
fects, the episcleral tissue 
and cornea ; and sometimes, 
scrofulous conjunctivitis. in complicated cases, it ex- 

tends to the choroid coat and iris. The disease is almost en- 
tirely confined to childhood ; it is said never to occur in infants 
at the breast, and it is rarely seen after puberty. 

Symptoms. — The disease seldom occurs in a purely 
simple form, but as already stated, is generally associated 
with more or less inflammation of the cornea and epis- 
cleral tissue, constituting what is called scrofulo-rheumatic 
ophthalmia. It is chiefly characterized by a number of 




SCROFULOUS CONJUNCTIVITIS. 1 39 

vessels occupying a circumscribed part of the orbital con- 
junctiva, generally that which borders upon the commissures 
of the eyelids, pursuing nearly a parallel course towards the 
cornea, and forming with each other fasciculi or bundles, which 
terminate abruptly near the edge of the cornea, without going 
beyond it. (See Fig. 6.) When, however, the disease is com- 
bined with catarrhal inflammation, the vessels may extend be- 
yond the border of the cornea, where they assume the fascicular 
form characteristic of the scrofulous injection. These fasciculi 
generally terminate in one or more small vesicles, called phlyc- 
taena, which, though not belonging exclusively to this affection, 
are nevertheless so characteristic of the disease, as almost to 
justify the term phlyctenular ophthalmia, by which it is some- 
times called. The vesicle or phlyctaena generally appears first, 
and afterwards the vessels which run towards it become inject- 
ed. The vesicle either dries up and disappears, or else breaks, 
leaving a superficial ulcuscle, which extends itself by ulceration. 
Sometimes the cornea, instead of being ulcerated, takes on a 
mammillated nebulous appearance, becoming as it were sanded 
or dotted over with a number of extremely fine points ; (non- 
vascular or diffuse keratitis ;) or a papulous exudation arises, 
(vascular keratitis) whichforms a grayish vascular covering to the 
cornea, giving rise to what is called pannus. 

The external redness, unless the disorder is complicated 
with catarrhal inflammation, is generally inconsiderable. On 
the other hand, owing partly to its combination with keratitis, 
and partly to nervous or ciliary irritation, the sensitiveness to 
light is so extreme as to constitute a distinguishing feature of 
the disease, under the name of photophobia scrofulosa. The 
access of light to the eye is so extremely painful as to cause the 
child to turn its head obstinately from the light, and, in severe 
cases, to hide away in the dark, or bury its face in its mother's 
lap, or in the bed. If the lids are forced open — which, how- 
ever, need never be done, as both the pain and photophobia 



140 PRACTICE OF MEDICINE. 

generally abate at dusk, when the child will open its eyes of its 
own accord — although the cornea is turned up so as to hide the 
pupil from view, the orbicularis palpebrarum muscle becomes 
spasmodically contracted on the globe, producing so much 
pressure as to cause the child to cry with pain. In uncomplica- 
ted cases, neither pain nor tears accompany the disorder ; but, 
as already stated, the complaint is generally associated with 
keratitis, so that, in addition to the pain — which, as already 
explained, depends partly upon inflammation of the cornea, 
and partly upon sympathetic or nervous irritation — there is 
generally a copious flow of tears, especially at the commence- 
ment of the disease. These greatly aggravate the complaint, 
by excoriating the parts over which they flow, producing more 
or less soreness and itching of the lids and face. This is still 
farther augmented by scratching and rubb'ing, which inflame 
the skin and sometimes give rise to an eczematous or impetig- 
inous eruption, which not only incrusts the affected parts, but 
may even extend over the head and body. 

Owing to the scrofulous disposition of the patient, the dis- 
ease has a natural tendency to become chronic, or at least to 
be reproduced by every new influence of an exciting cause, so 
that after one attack has been overcome, another frequently 
takes its place, either in the same or the other eye, and thus the 
disease may continue for months and years, and perhaps never 
reach a permanent and satisfactory conclusion. 

RESULTS. — The pustules or phlyctaena which form at the 
extremities of vascular fasciculi, or near the junction of the 
cornea with the sclerotica, frequently ulcerate, the ulcers some 4 
times extending superficially, at others penetrating into the 
corneal substance ; in the latter case they may open into the 
anterior chamber, and cause prolapsion of the iris. In addition 
tion to these results, we have in some instances, pannus, inter- 
amellar effusions into the cornea, onyx, hypopion, leucoma, 
synechia anterior, and staphyloma. When the inflammation 



SCROFULOUS CONJUNCTIVITIS. 141 

extends to the choroid coat and iris, alterations, more or less 
serious, of those membranes occur. 

DIAGNOSIS. — Scrofulous ophthalmia is generally easily 
distinguished by the great intolerance of light, the vesicular 
elevations of the conjunctiva, the vascular fasciculi, and the co- 
existence of scrofulous symptoms in other parts of the body. 
When, as frequently happens, the absorbent glands of the neck 
are inflamed and swollen, the alae of the nose red, swollen and 
excoriated, and the ears sore and excoriated behind ; and when, 
in addition to these symptoms, there is a disordered state 
of the stomach and bowels, generally characterized by a fetid 
breath, furred tongue, morbid appetite, swollen abdomen and cos- 
tiveness, it is scarcely possible to mistake the affection. Indeed, 
such is the severity of the ciliary irritation and consequent pho- 
phobia in these cases, as of itself to constitute an almost certain 
guide to the nature of the complaint. It is well to remember, 
in this connection, that there is a troublesome form of ophthal- 
mic inflammation occurring in strumous children, which is main- 
ly dependent upon the state of the primae viae and skin, but 
which does not exhibit, in any marked degree, the features of 
ordinary scrofulous ophthalmia. There is generally more ex- 
ternal redness, especially of the lids, and but little intolerance 
of light ; still the disease is esentially scrofulous in its nature, 
and, like other scrofulous diseases, is extremely obstinate, and 
and continually apt to recur. 

PROGNOSIS. — This, so far as vision is concerned, is gener- 
ally favorable, provided the cornea remains clear, or, if opaque, 
the opacity is merely superficial, or is simply owing to intersti- 
tial deposition. Vascularity and inter-lamellar depositions gen- 
erally disappear soon after the subsidence of the inflammation ; 
even pannus, though it may last a long time, does not endanger 
the sight. Ulceration produces more or less permanent opacity ; 
and when extreme, especially if attended with prolapsion of the 
iris, it generally causes serious injury to vision. Staphyloma 



142 PRACTICE OF MEDICINE. 

and bursting of the cornea are of course always attended by 
the most disastrous consequences. 

Etiology. — The chief predisposing cause of scrofulous 
ophthalmia is a strumous condition of the system. The excit- 
ing causes are such as, by depressing the vital powers, are cal- 
culated to call into action the scrofulous diathesis, such as cold, 
damp and variable weather, inadequate clothing, poor and im- 
proper nourishment, dark and unwholesome dwellings, insuffi- 
cient exercise in the open air, disorders of the digestive system, 
and an inactive state of the skin, bowels and uterine organs. 
It likewise occurs, for the same reason, after any protracted ill- 
ness, such as the various exanthemic fevers, whooping cough, 
etc. On the other hand, if the strumous disposition be strong, 
the disease may by provoked by mechanical injuries, excessive 
use of the eyes, want of cleanliness, and even by a change of 
season. Not unfrequently the disease alternates with other af- 
fections, such as otorrhcea, cutaneous eruptions, etc. 

Tteatment. — This should be general as well as special, 
that is to say, the treatment should be directed against the gen- 
eral unhealthy state of the system — the scrofulous diathesis — 
as well as against the attack itself ; this is necessary in order 
both to remove the local affection and prevent relapse. The 
treatment should also have relation to the particular form of 
the attack, whether as simple or complicated ; the former will 
require, more especially, the antipsoric remedies, such as Calca- 
rea, Hepar sulph., Sulphur, etc. ; while the latter will require 
those best adapted to the particular complications, such as Bel- 
ladonna, Mercurius, etc. 

Cold applications are, as a general rule, injurious to scrofu- 
lous sore eyes, and should therefore seldom be employed ; 
never, indeed, unless the inflammation is combined with some 
other form of ophthalmia ; even in these cases warm applica- 
tions will be more suitable, and will commonly give most relief. 
It is generally sufficient, so far as local treatment is concerned, 



SCROFULOUS CONJUNCTIVITIS. 1 43 

to bathe the eyes frequently with tepid water, and to shade 
them with a stiff crescent-shaped screen, which is preferable to 
a bandage, as it neither overheats the eyes, nor deprives them 
of the beneficial effects of fresh air. 

The principal remedies for scrofulous ophthalmia are the 
following : 

Acidum Nitricum is especially adapted to protracted cases, 
particularly when the cornea has become nebulous, or clouded 
with dark spots. 

Apis mellifica. — This remedy, though it appears to be indi- 
cated in many cases, is generally of doubtful value. We have 
commonly found it to prove most useful in the first stage of 
purely scrofulous cases, attended with burning and stinging 
pains, redness of the conjunctiva, extreme photophobia and 
lachrymation, a nebulous state of the cornea, and an eczematous 
eruption on the lids and face. 

Arsenicum* — This remedy is particularly adapted to pro- 
tracted cases, especially such as are subject to frequent relapses, 
characterized by photophobia, keratitis, redness of the lids and 
burning, itching and excoriation of the surrounding integuments. 

Bellado7i7ia.-\ — This medicine is indicated in cases compli- 
cated with catarrhal or rheumatic ophthalmia, especially if the 
pains are accompanied with acute febrile symptoms. 

Calcarea Carb.% — One of the best antipsoric remedies, 
especially adapted to purely scrofulous cases of a protracted 
character, and subject to frequent relapses. 

Cannabis sat. is indicated in chronic cases attended with 
corneal opacity. 

Conium mac. — Chronic cases, attended with photophobia, 

* See Am. Horn. Obs.^ vol. vil, pp. 120, 121. (3d and 30th.) 

t Ibid. (3d). 

% See Am. Horn. Obs., vol. vii. p. 120. {30th and 200th») 



144 PRACTICE OF MEDICINE. 

spasms of the orbicularis, redness, burning and itching of the 
eyes and lids, and an eczematous or impetiginous eruption, 
with soreness and excoriation of the neighboring parts. 

Graphites. — This remedy is adapted to both acute and 
chronic cases, especially if accompanied with eruptions in the 
face and behind the ears. 

Hepar sulph* — This is one of the best anti-scrofulous rem- 
edies, particularly adapted to protracted and relapsing cases, 
especially if attended with ulceration of the cornea. 

Mercurius. — This medicine is well adapted to both acute 
and chronic cases, being equally applicable to the inflammatory, 
exudative and ulcerative stages of the complaint. It is one of 
our most valuable remedies for scrofulous ophthalmia, and 
should therefore, in most cases, be used early, and not too 
hastily discontinued. 

Pulsatilla. — This medicine being well adapted to lym- 
phatic constitutions, is especially suited to those cases depend- 
ing on stomachic and uterine derangements, whether acute or 
chronic. 

Rhus tox/* — This remedy, notwithstanding its somewhat 
doubtful indications, has done good service in scrofulous oph- 
thalmia, especially when attended with photophobia, lachryma- 
tion, spasms of the lids, and exanthematous or herpetic erup- 
tions. 

Silicea. — This remedy is well adapted to chronic cases, at- 
tended with ulceration and opacity of the cornea, swelling of 
the cervical glands, and cutaneous eruptions on the lips and 
face. 

Staphysagria. — This medicine has been found useful in 
scrofulo-rheumatic ophthalmia, accompanied by spasmodic 
closure of the lids, glandular swellings, and cutaneous eruptions. 

Sulphur* — This powerful antipsoric remedy is indicated 

* See Am. Horn. Obs., vol. vii., pp. 120. 121. {3d and 30th.) 



PHLYCTENULAR CONJUNCTIVITIS. 145 

in all chronic and relapsing cases, especially when the cornea 
is deeply involved, as in pannus, ulceration, interstitial deposi- 
tion and onyx. 

The remedies above mentioned are those of chief import- 
ance in the treatment of the ordinary forms of scrofulous oph- 
thalmia ; but inasmuch as the disease is frequently complicated 
with other forms of ophthalmic inflammation, the prescriber is 
referred for additional remedies* and details to Tables XIV. 
and X V. ; and also to the Theraptutic Indications given at the 
end of the Section on Ophthalmic Diseases. 

DIET AND REGIMEN. — The diet should be of the most 
nourishing and digestible character, consisting, for the most 
part, of good home-made wheat bread, graham bread, oat-meal 
pudding, fresh butter, tender and juicy beef, good ripe fruit, 
dried fruit, etc. ; while all such articles as pork, sausage, bacon, 
veal, coffee, pickles, pastry, etc., should be rigidly excluded. 

Suitable and adequate clothing, with proper attention to 
light, air and exercise, will do much to ward off the disease from 
those that are predisposed to the affection, and to mitigate it 
when established. 

5-PHLYOTENULAR CONJUNCTIVITIS. 

APTHOUS, HERPETIC OR PHLYCTENULAR OPHTHALMIA. 

Fig. 7 

Phlyctenular Conjunctivitis, 
or, as it is sometimes impro- 
perly called, pustular ophthalmia, 
is a mild form of conjunctivitis, 
characterized by an eruption of 
phlyctenular conjunctivitis. vesicles, called phylyctcence ox phly- 
ctenules, on or near the margin of the cornea. The eiuption 
first makes it appearance in the form of small red, slightly 
elevated points upon the inflamed conjunctiva oculi ; these 
points as they enlarge develope into vesicles ; and finally, if the 

* See Am. Horn. O&s., vol. vi, p. 559. 
*9 




146 PRACTICE OF MEDICINE. 

inflammation goes on unchecked, the vesicles burst and form 
ulcers, which in mild cases gradually disappear, but in others 
manifest a disposition to spread. Numerous vessels, or bundles 
of vessels, {vascular fasciculi,) run toward the cornea, but never 
pass beyond the borders of the vesicles or ulcers, in which they 
always terminate. {See Fi%. 7.) The phlyctaenae vary in size 
as well as in number, solitary ones being sometimes nearly as 
large as a split pea ; generally, however, they are much smaller, 
their relative dimensions being usually in an inverse ratio to 
their number. Phlyctaenae are not peculiar to this form of 
ophthalmia, being, as we have already seen, sometimes observed 
in other forms of conjunctivitis, especially the catarrhal and 
scrofulous ; indeed, some opthalmologists regard the phlyctenu- 
lar as a modification of strumous conjunctivitis, intermediate in 
character between the catarrhal and scrofulous. Like the latter, 
it is almost entirely confined to children, but unlike it is seldom 
attended with ciliary irritation and photophobia, though gene- 
rally occurring in scrofulous subjects. It is only when the 
vesicles are numerous, and are situated wholly or partly on the 
cornea, that there is much intolerance of light, lachrymation, or 
ciliary irritation. 

Treatment. — Many cases are so mild as to require little 
more, in the way of treatment, than rest and protection of the 
organ. When arising from fatigue, the irritation of dust, or 
other similar causes, hygienic measures alone will generally 
suffice. This is especially true if the vesicles are solitary, or but 
one or two in number, and are situated over the sclerotica. 
Severe cases are benefited by warm fomentations, and by the 
particular treatment recommended for scrofulous conjunctivitis, 
(which see.) The most efficient remedy for ulceration is Mer- 
curius, which may be prescribed with as much confidence in 
this affection as in aphthous stomatitis. Other remedies which 
have been found most useful for particular conditions, are the 
following : 

Ciliary Neuralgia : Atrop., Bell., Cham., Spigel. 



ERYSIPELATOUS CONJUNCTIVITIS. 147 

Photophobia : Ant. tart., Ars., Bell, Con., Hepar, Merc, 
Spigel. 

Ulceration, with or without ciliary irritation and photopho- 
bia : Ars., Merc. 

Obstinate, the disease appearing to be seated in the sub-con- 
junctival tissue : Ars., Cham., Merc. 

6-ERYSIPELATOUS CONJUNCTIVITIS. 

This form of ophthalmic inflammation is seated in the orbi- 
tal conjunctiva, and in the subjacent cellular tissue. The 
injection of the conjunctival vessels becomes rapidly confluent, 
the membrane swells, assumes a uniform pale red color, be- 
comes relaxed and wrinkled, except at the lower part of the 
globe, where it remains tumefied and presents a more or less 
oedematous appearance. As there is neither epiphora nor 
photophobia, it is reasonable to infer that the deeper structures 
are not involved. This description, however, applies only to 
idiopathic cases ; when secondary to facial erysipelas, the 
inflammation is generally of much greater severity. In these 
cases the episcleral and neighboring tissues sometimes 
participate, and then there is a deeper redness, with more or 
less intolerance of light and ciliary irritation. As an idiopathic 
affection, it is mostly confined to persons who have reached the 
period of middle life, or beyond, and whose constitutions are 
generally more or less debilitated. The chief exciting cause is 
cold, though the disease is sometimes of epidemic origin. 

TREATMENT. — Aconite and Belladonna, with warm fomenta- 
tions, generally constitute all the treatment required. When 
secondary to facial erysipelas, remedies should be selected 
with special reference to the primary disease. See Erysipelas 
of the Head and Face. 

7-EXANTHEMATOUS CONJUNCTIVITIS. 
The contagious exanthemata are accompanied by inflam- 
mations of the conjunctiva corresponding in intensity to the 



I48 PRACTICE OF MEDICINE. 

eruptive inflammations of the skin with which they are asso- 
ciated. As they seldom demand special treatment, and are, for 
the most part, neither sufficiently important nor peculiar to 
require minute description, we shall give them but brief con- 
sideration. 

A— Scarlatinous and Rubeolous Conjunctivitis. 

OPHTHALMIA SCARLATINOSA AND MORBILLOSA. 

In scarlatina and measles, we have more or less redness and 
inflammation of the external membranes of the eye, with mode- 
rate pain or uneasiness, lachrymation, and sensibility to light. 
Sometimes, though rarely, phlyctaenae and ulcers also appear 
upon the cornea, and occasionally interstitial depositions take 
place between its laminae. The ophthalmic disorder generally 
keeps pace with the cutaneous affection. It is less frequently 
associated with scarlatina than with measles, of which it is a 
common attendant. 

Treatment. — When the conjunctiva alone is affected, the 
treatment is the same as required for catarrhal ophthalmia, 
(which see.) Cool and tepid washes are generally agreeable, 
and with protection from light, and the occasional administra- 
tion of Aconite, the inflammation usually runs a satisfactory 
course. When the exanthemata are succeeded by severe con- 
junctivitis extending to the submucous tissues, and especially 
when attended with ulceration of the cornea, the treatment 
should be much more active, in order to prevent opacity and 
loss of vision. In these cases, Aconite and Mercurius, with the 
diligent use of the cold compress, will be required. 

B— Variolous Conjunctivitis. 

OPHTHALMIA VARIOLOSA. 

This form of ophthalmia is seated in both the orbital and 
palpebral conjunctiva, and in the cutaneous covering of the lids. 
It occurs conjointly with, and subsequently to the variolous 
disease ; and not unfrequently it assumes a chronic form. 



VARIOLOUS CONJUNCTIVITIS. 149 

Most commonly it is confined to the lids, the external surface 
of which, with their ciliary margins, are covered with a greater 
or less number of variolous pustules, which produce extensive 
swelling, and close the eyes. As the eruption declines, the 
swelling abates, and the globe of the eye is found uninjured. 

In a small proportion of cases, however, (stated by some 
authorities at about four per cent, of the whole number,) the 
inflammation likewise involves the conjunctiva and cornea. 
This is what constitutes the true variolous ophthalmia, and is 
always a dangerous disease. The inflammation is so violent, 
and proceeds with such rapidity, as to cause suppuration and 
more or less sloughing. The results are in proportion to the 
extent and violence of the inflammation. Staphyloma, prolap- 
sion of the iris, synechia anterior, obliteration of the pupil, 
opacity of the cornea, collapse of the globe, and partial or com- 
plete blindness, are not uncommon terminations. 

Treatment. — The suppurative form of variolous ophthal- 
mia, which does not generally set in until after the decline of 
the cutaneous affection, requires the same treatment as purulent 
conjunctivitis, (which see.) Treatment for the palpebral in- 
flammation will be given in the next article (which see.) 

ART. II. — BLEPHARITIS. 

The term blepharitis, signifying inflammation of the eyelids, 
is a general one, and may therefore be properly used to denote 
any variety of inflammation to which the lids are subject ; but 
inasmuch as these inflammations are mostly of a subacute or 
chronic character, as they occur for the most part in scrofulous 
subjects, and as they are chiefly limited to the tarsal borders ; 
in other words, as they possess many features in common, we 
shall include under it the several conditions known as Ophthal- 
mia Tarsi, Psorophthalmia, Blepharitis Ciliaris, Eczema Pal- 
pebrarum, etc., reserving the more acute, but less common forms 
of palpebral inflammation for separate consideration. 



150 PRACTICE OF MEDICINE. 

I-BLEPHAEITIS OILIAEIS. 

FOLLICULAR INFLAMMATION GF THE LIDS. 

Blepharitis ciliaris is an ulcerative inflammation of the edges 
of the eyelids, depending on a psoric or scrofulous condition 
of the system, or occurring as a sequence of measles and other 
exanthemata, styes, etc. 

Symptoms. — The disease commences as an eczematous 
inflammation of the cuticle of the edge of the lid, the epidermis 
of which either desquamates or suffers ulceration. The inflam- 
mation and ulceration produce suppuration, and the purulent 
matter collecting at the roots of the cilia forms scabs, beneath 
which the ulcerative process continues. As the ciliary follicles 
become inflamed, the cilia loosen and drop out. The inflam- 
mation also invades the meibomian glands, or follicles, which 
with the ciliary apertures may become permanently occluded. 
In this manner the disease may continue until the whole ciliary 
border becomes ulcerated, the outer surface of the lids, as well 
as the conjunctival lining, inflamed, the cilia destroyed, the 
tarsal edges thickened and indurated, and the puncta lachry- 
malia everted, so that the tears overflow the lids ; ultimately, 
the skin contracts so as to cause more or less ectropium. This 
is the state called lippitudo or blear eye. Sometimes, in chronic 
cases, the edges of the lids turn inwards instead of outwards, 
producing trichiasis and entropium. The cilia by constant 
contact with the globe may inflame the cornea, causing a super- 
ficial vascular keratitis which may result in pannus. 

Results. — These are: loss of cilia, epiphora, lippitudo, 
ectropium, entropium, trichiasis, diatrichiasis, opacity of the 
cornea, pannus, and more or less impairment of vision. 

ETIOLOGY. — In addition to the causes already enumerated, 
namely, scrofula, small pox, measles, erysipelas, etc., may be 
mentioned such causes as cold and damp air, smoke, dust, and 
other irritants, especially when acting on a psoric or strumous 
constitution. 



Blepharitis ciliaris. 151 

PROGNOSIS. — This disease is always protracted, and subject 
to frequent relapses. In its earlier stages, before ulceration has 
involved the entire margin of the lids, destroyed the cilia, and 
produced hypertrophy of the palpebral tissues, the disease may 
be cured ; but after these changes have occurred, it only admits 
of palliation. 

TREATMENT. — The edges of the lids should be kept free from 
scabs and purulent accumulations by cleansing them as often 
as may be necessary with tepid water, after which they should 
be bathed with some mild astringent lotion, such as a weak 
solution of alumen or muriate of hydrastia. At night, they 
should be anointed with simple cerate or spermaceti, in order, 
to prevent as far as possible, their becoming glued together 
with the discharges ; and in the morning the agglutinating mat- 
ter should be softened with tepid milk and water, or, what is 
better, with warm cream, until the lids can be separated with- 
out the use of force, the employment of which will surely aggra- 
vate the disease. If trichiasis exists, the inverted hairs should 
be carefully removed, as they are not only a great annoyance 
to the patient, but they keep up such a constant irritation as 
greatly to aggravate the inflammation, and ultimately produce 
opacity of the cornea. Stimulating ointments without number 
have been recommended, but the most popular, and, in most 
cases effective, is the red precipitate, of the strength of 
about fifteen grains tb the ounce of simple cerate, which should 
be carefully applied to the tarsal edges at night. 

The internal treatment should be similar to that recom- 
mended for scrofulous ophthalmia, (which see.) Consult also, 
the article Scrofula ; likewise, Tables XIV. and XV. and the 
Therapeutic Indications at the end of the section on Oph- 
thalmic Diseases. 

Diet and Regimen. — The diet should be carefully re- 
gulated ; and should consist of nutritive and easily digestible 
food, such as milk, soft boiled eggs, and wholesome meats, 
stale bread with fresh butter, and a due admixture of fresh 



152 PRACTICE OF MEDICINE. 

vegetables and fruit. The clothing, also, should be carefully 
attended to, so as to protect the patient against the effects of 
sudden atmospheric changes. Special caution should be ob- 
served against reading at night, or exposing the eyes to dust 
and smoke, or to the glare of the sun, gas and other bright 
lights. Frequent ablutions, exercise and fresh air, are import- 
ant adjuvants in the treatment and should not be overlooked. 

2-INFLAMMATIO PALPEBRARUM. 

SIMPLE INFLAMMATION OF THE LIDS. 

Simple inflammation of the eyelids is characterized by red- 
ness, swelling and soreness of the tarsal border, whence it 
spreads over the entire lid. It is generally of catarrhal origin, 
and is almost always associated with more or less conjunctivitis. 
When severe, the cellular tissue is apt to become involved, 
giving rise to oedema and in some cases to abscess. 

CBd^ma. — Effusion of serum into the cellular texture of the 
eyelid, is a frequent result of ophthalmic inflammation, whether 
simple or specific. When severe, as in the various forms of 
purulent ophthalmia, the tumefaction of the lids becomes very 
great, the upper projecting over the lower, and presenting a 
smooth convex surface of a bright red color. In other cases, 
the vascular congestion is such as to cause considerable swelling 
with little or no external redness. In inflammation of the 
lachrymal sac, the lids are often greatly distended, subsiding 
only when the cause is removed. CEdema of the lids also 
occurs in cases of hordeolum, or stye, from the bites and stings 
of insects, from erysipelas and anasarca of the face, and from 
other causes. 

Abscess, though necessarily dependent upon inflammation, 
is frequently the result of injury. It may form on either side 
of the palpebral cartilage, or it may exist in both situations at 
the same time; consequently, the matter may approach the 
surface in either direction. Neglected cases sometimes result 



KERATITIS. 153 

in very great deformity, giving rise to ectropium or lagophthal- 
mus, and sometimes to both. 

TREATMENT. — For simple uncomplicated inflammation of 
the lids, Aconite, or Aconite and Belladonna in alternation, with 
the early use of the cold compress, is generally sufficient to effect 
a cure. CEdema usually requires Apis, Arsenicum or Rims tox. 
Abscess calls for such additional remedies as Hepar, Silicia 
and Calcarea. In order to prevent deformity, the lancet should 
be used as soon as fluctuation can be detected, being careful to 
make the incision in a horizontal direction, so that the cicatrix 
remaining may be concealed by the natural folds of the in- 
tegument. 

ART. III. — KERATITIS. 

Inflammation of the cornea is not only frequently associated, 
as we have seen, with several forms of ophthalmia, but also 
occurs as a primary or idiopathic affection. It is only when 
the inflammation begins in the cornea, however, that the disease 
is to be classed as keratitis. The affection assumes a great 
variety of forms, according as it is simple or complicated, vas- 
cular or non-vascular, inflammatory or non-inflammatory, partial 
or total, acute or chronic, active or indolent, fascicular, phlyc- 
tenular, diffuse, suppurative, neuro-paralytic, etc. These and 
various other distinctions we shall find it convenient to con- 
sider under the following four heads, namely: (1) diffuse kera- 
titis ; (2) suppurative keratitis ; (3) vascular keratitis, and (4) 
phlyctenular keratitis. Keratitis punctata being a secondary 
form will be described under iritis. (See Serous Iritis) 

1-DIFFUSE KERATITIS. 

PARENCHYMATOUS, OR INTERSTITIAL CORNEITIS. 

SYMPTOMS. — Diffuse inflammation of the cornea, when 
fully formed, is characterized by more or less impairment ot 
vision from interstitial deposition. At first the cornea has a 
somewhat hazy, cloudy, or smoky appearance, which partially 
impedes the transmission of light. This condition is called 



154 PRACTICE OF MEDICINE. 

nebula, and constitutes the slightest form of corneal opacity. 
As the disease progresses, the opacity increases, and vision 
becomes less and less distinct ; but owing to inequalities in its 
developement, the sight is less troubled than it would otherwise 
be. This arises from the fact that clearer, or less affected por- 
tions of the cornea remain scattered among the more opaque, 
as if the infiltration had occurred only in detached points, 
though as a general rule the opacity first begins at the limbus, 
where its density is greatest, and spreads gradually more and 
more towards the centre, until finally it involves the whole cor- 
nea. Sometimes, however, the reverse of this occurs ; the infil- 
tration beginning at or near the centre, and gradually extend- 
ing towards the circumference. The more opaque parts are 
sometimes of a yellowish hue, as though suppuration had oc- 
curred there, but this is seldom the case in the form of keratitis 
we are now considering. In addition to these changes, the 
Fi s- 8 surface of the cornea loses its usual 

polish and becomes unequal, as if sand- 
ed or dotted over with fine points. {See 
Fig. 8) It is this fine stippled ap- 
pearance ol the surface which causes 
nebulous vision, and gives to the eye 
its peculiar dull expression at the be- 
ginning of the complaint. 

KERATITIS. 

The degree of inflammation and vascular injection, varies 
greatly in different cases. Sometimes the injection is incon- 
siderable, and then the disease is called non- vascular. In other 
cases, with a varying amount of conjunctival injection, the 
disease is marked by a zone of deep parallel vessels running 
towards the cornea — the distended trunks of which lie beneath 
the conjunctiva, in the sub-conjunctival or episcleral tissue, and 
known as the episcleral or circumcorneal zone — whose minute 
branches or extremities passing the border of the cornea, form 
upon the limbus a small circle, or oftener a segment of a circle, 




DIFFUSE KERATITIS. 155 

of a dark red tint, which presents a marked contrast with the 
opaque centre of the cornea and the pink-colored zone of the 
border. {See Fig. 8,) Vascular diffuse keratitis is also charac- 
terized by the presence of delicate vessels in the deeper layers 
of the cornea, extending from the corneal zone to the several 
centres of exudation. 

In addition to the above symptoms, diffuse keratitis also 
gives rise to more or less ciliary irritation, photophobia and 
lachrymation, especially on exposure to light. Occasionally 
these symptoms are so slight as scarcely to attract attention ; 
but in the majority of cases they are quite marked, especially 
at the beginning of the disease, and before exudation has taken 
place. Afterwards, as the process of infiltration goes on, they 
generally become less prominent and sometimes disappear alto- 
gether; in some cases, however, they remain unchanged or 
with varying degrees of intensity throughout the progress of the 
disease. Having reached its height, the affection frequently 
continues for weeks and months apparently stationary before 
beginning to decline. The retrograde metamorphosis takes 
place with great slowness, and several months often elapse 
before the cornea fully recovers its transparency. Vascular 
diffuse keratitis generally runs its course more rapidly than the 
non-vascular which is extremely indolent. 

The disease is seldom confined to one eye ; the second eye 
is generally attacked soon after the first. This is very dis- 
couraging to the patient, and it is generally difficult to make 
him believe that he is not going blind. The affection is fre- 
quently complicated with iritis, irido-choroiditis, cyclitis, or 
with some other form of keratitis. As the iris is hid from view 
during the progress of the case, the practitioner should be par- 
ticularly on his guard, lest when the cornea becomes clear he 
find his patient affected with posterior synechia. 

ETIOLOGY. — Diffuse keratitis has been called syphilitic, 
under the mistaken notion that it owes its origin to hereditary 



156 PRACTICE OF MEDICINE. 

syphilis. There is probably no good foundation for this belief, 
any more than there is for referring it to scrofula or tubercu- 
losis. It is true it is frequently met with in persons affected 
with hereditary or constitutional syphilis, but it is also true 
that it occurs just as often in those in whom not a trace of 
syphilitic taint can be discovered. The disease occurs at all 
times and under all conditions of life ; but chiefly in children 
between the ages of ten and fifteen years, especially those of a 
delicate constitution, many of whom are more or less weakly, 
anaemic and scrofulous. It is highly probable, therefore, that 
delicacy of constitution, defective nutrition, or a broken-down 
state of the system — in short, deficient vital action — contribute 
more to its production than syphilis, either hereditary or 
acquired. 

PROGNOSIS. — This is generally favorable ; for notwithstand- 
ing its chronicity and tendency to relapse, the disease is seldom 
attended with ulceration, and, if properly treated, the cornea 
finally clears up, leaving little if any trace of its previous dis- 
eased condition. Some slight inequality in its curvature may 
remain, however, especially if there has been much bulging 
from intra- ocular pressure; but the causes which commonly 
give rise to this condition generally prove more serious in other 
ways. Hence the prognosis will be more or less favorable, 
according as the inflammation affects the deeper tissues of 
the eye. 

Treatment — The employment of caustics, or even astrin- 
gent collyria, should be carefully avoided, as such applications 
not only do no good, but often do much harm. This caution 
is all the more necessary, as the temptation to use them is 
often stimulated by the importunities of the patient, under the 
idea that the long duration of the disease may in this way be 
abridged. The danger lies in their tendency to cause serious 
complications, such as iritis, cyclitis, ulceration of the cornea, 
etc. Atropine should be instilled as soon as it can be well 



DIFFUSE KERATITIS. 157 

borne, for although it will not be absorbed to any great extent 
until the cornea begins to clear, it is important to obtain its 
early action in dilating the pupil, ' and thereby prevent the 
formation of posterior synechias, (See Iritis}) Paracentesis 
and iridectomy prove useful in accelerating the cure, and some- 
times succeed in arresting the disease at an early stage. They 
are especially indicated if symptoms of cyclitis supervene, or if 
there is continued increase of intra-ocular pressure. (See 
Iritis and Cyclitis) In very chronic cases, especially those of 
the non-vascular variety, Von Graefe recommends the employ- 
ment of warm compresses. If used with sufficient care in this 
class of cases, and discontinued immediately they have fulfilled 
their mission, namely, to stimulate the action of the bloodves- 
sels of the cornea, they will doubtless do much good in pro- 
moting absorption of the exudations ; but it is evident that 
such applications cannot be safely left to the judgment of 
inexperienced attendants. The same end may be accomplished 
by applying mild irritants, such as Mercurius dulcis, to the dis- 
eased membrane. This may be employed once a day by 
insufflation with great advantage, being careful to see that the 
calomel is pure and free from lumps. Wells recommends a 
collyrium of Kali hydriod, (gr. ij. @ ?j) for the same purpose. 

THERAPEUTIC INDICATIONS. 

Aconite. — This remedy is useful whenever the vascular re- 
action is in excess. 

Arsenicum. — This is one of the best internal remedies for 
ulceration of the cornea, and is also frequently serviceable in a 
weak and impoverished state of the general system. 

Belladonna is indicated whenever there is much conjunctival 
injection and ciliary neuralgia. 

Cactus frequently relieves nervous and vascular irritation in 
the ciliary region, and also the accompanying asthenopia. 

Cimicifuga. — This remedy is often useful when there is much 
neuralgia and ciliary irritation. 



158 PRACTICE OF MEDICINE. 

Conium is often a valuable remedy in allaying photophobia, 
especially when accompanied with much ciliary irritation. 

Gelseminum is indicated in cases attended with asthenopic 
symptoms and photophobia, especially when associated with 
marked hyperemia and hyperesthesia of the retina and ciliary 
nerves. 

Hepar sulph. — This remedy is useful in promoting absorp- 
tion of the exudation and clearing the cornea, more particularly 
in indolent and chronic cases. 

Kali hydriodicum is an important constitutional remedy, 
especially in syphilitic cases. 

Mercurius is very servicable in cases attended with ulcera- 
tion, either with or without photophobia, but is more particu- 
larly useful in promoting interstitial absorption. It may often 
be advantageously alternated with Hepar sulphuris. 

Nitric acid is especially indicated when, in addition to 
photophobia, lachrymation and nervous irritation, the patient is 
laboring under syphilitic dyscrasia, or a weak and impoverished 
state of the constitution. 

Spigelia. — This is one of our best remedies for ciliary irrita- 
tion and neuralgia, especially when there is much hyperemia 
of the ciliary vessels, and photophobia. 

For additional remedies, see Tables XIV and XV., and con- 
sult the Therapeutic Indications at the end of the section on 
Ophthalmic Diseases. 

Diet and Regimen. — The diet will in most cases require 
to be of the most liberal and nutritious character, consisting 
chiefly of such articles as roast beef, eggs, milk and other kinds 
of nitrogenous food, together with a due proportion of vegeta- 
bles and ripe fruit. In some cases benefit will be derived from 
partaking freely of malt liquors, wine, kumiss, and other like 
stimulants. 

Care should be taken, by shading the eyes or otherwise, not 
to expose them while under treatment to any irritating or in- 



SUPPURATIVE KERATITIS. 1 59 

jurious influences, such as wind, dust, smoke, heat, bright light, 
etc., and at the same time to guard against the debilitating 
effects of confinement and vitiated air, by regular out-door 
exercise, ventilation and the observance of such other hygienic 
regulations as the habits and surroundings of the patient may 
demand. 

2.-SUPPURATIVE KERATITIS. 

SYMPTOMS. — Suppurative Keratitis is characterized by the 
development of purulent collections in the substance of the 
cornea, and by ulceration and disintegration of its tissues. 
These changes are generally preceded and accompanied by 
symptoms denoting high inflammatory action ; while on the 
other hand we sometimes meet with cases in which the symp- 
toms of inflammation and ciliary irritation are almost entirely 
absent. 

In the inflammatory form, as it is called, the conjunctival 
and episcleral injections are strongly marked, the corneal zone 
being of a bright rose color ; generally, also, there is severe cil- 
iary neuralgia, with photophobia and lachrymation. The pupil 
is frequently much contracted, and there is also, in most cases, 
more or less chemosis. We first notice a small grayish opacity, 
generally near the center of the cornea, which afterwards 
becomes cream-colored or yellow, the infiltrated tissue breaking 
down into an abcess, which may find its way to the surface, 
forming an ulcer of corresponding depth. Or several small 
abcesses may coalesce and form a corneal abscess of large 
dimensions. Sometimes the pus sinks down between the 
lamellae of the cornea, separating them, and leaving a condi- 
tion called onyx, from its resemblance to the lunula of the 
nail. This may be so small as to be difficult of detection, 
appearing only as a narrow yellow line near the limbus of the 
cornea, or so large as to cover more or less of the pupil, when 
it may be mistaken for an hypopyon. The latter is generally 
due to the bursting of a corneal abcess, and the precipitation 



160 PRACTICE OF MEDICINE. 

of its contents at the bottom of the anterior chamber. It may 
also arise from inflammation of the iris, as will be explained 
under iritis. 

The non-inflammatory form of suppurative keratitis is 
distinguished by the absence, more or less complete, of all the 
usual symptoms of the inflammatory form. Thus, there is 
little or no ciliary neuralgia, photophobia or lachrymation ; the 
sensibility of the eye is also greatly diminished, responding 
imperfectly, and as it were with difficulty, to external irritation. 
Sometimes the disease sets in with the usual symptoms of 
inflammatory irritation and severe ciliary neuralgia, and then 
these symptoms suddenly disappear, the cornea rapidly break- 
ing down, and forming abcesses of a deeper and more uniform 
yellow color than those of the inflammatory variety. The 
tendency in this form of keratitis, is to rapid suppuration and 
sloughing of the corneal tissue, the suppurative process extend- 
ing in circumference rather than in depth, contrary to what 
usually occurs in the other form. The inflammation frequently 
extends to the iris, and then we are apt to have large hypop- 
yon. (See Iritis.) 

ETIOLOGY. — Suppurative keratitis sometimes results from 
paralysis of the fifth pair of nerves, and is then called neuropara- 
lytic keratitis. If the paralysis is incomplete, the cornea frequent- 
ly escapes, or is but partially and lightly affected ; but when com- 
plete, the entire cornea is generally involved, becoming opaque, 
swollen and discolored from purulent infiltration ; ulceration 
ensues, and more or less of the corneal texture is destroyed. 
Neuro-paralytic keratitis is supposed to be due, not to mal-nu- 
trition of the cornea, but simply to the irritation excited by 
external irritants, such as air and dust, the action of which is 
allowed to continue in consequence of the insensibility of the 
eye. Meissner and others, however, have shown that this form 
of keratitis is not entirely due to insensibility of the organ, 
deeming it probable that the integrity of the nerve renders the 
eye mor: able to resist the noxious effects of external irritants. 



SUPPURATIVE KERATITIS. l6l 

Suppurative keratitis, both inflammatory and non-inflam- 
matory, is frequently of traumatic origin. This is most 
frequently the case in the aged and infirm, especially after 
operations upon the cornea, such as cataract ; also after 
mechanical or chemical injuries arising from blows, or from the 
lodgment of foreign bodies, such as bits of steel, in the sub- 
stance of the cornea. The inflammatory form is met with in 
severe cases of purulent and diphtheritic conjunctivitis ; and 
the non-inflammatory, after certain very debilitating diseases, 
such as cholera, diabetes, typhus fever, etc. 

PROGNOSIS. — From what has been said, it follows that in 
most cases the cornea suffers irreparable injury, especially in 
the non-inflammatory form. Perforation of the cornea fre- 
quently occurs, followed by extensive ulceration and sloughing, 
the formation of anterior senechia and staphyloma, and, when 
the deeper tissues of the eye are involved, the disease may end 
in panophthalmitis and atrophy of the globe. On the other 
hand, ulcers may heal without permanent opacity, onyces and 
hypopya may be rapidly absorbed, anterior senechiae may be 
broken through, and in a large proportion of cases, under pro- 
per treatment, the cornea may preserve its continuity, and 
regain to a great extent its transparency and usefulness. 

Treatment. — In the inflammatory form of suppurative 
keratitis, attended with high vascular and nervous excitement, 
chemosis, etc., frequent instillations of a neutral* solution of 
the sulphate of atropine, together with the diligent use of cold 
compresses, will be required. If the abscess is so situated that 
perforation would endanger prolapsion of the iris by dilatation, 
that is, towards the circumference of the cornea, the atropine 
should be omitted, and, if necessary, calabar bean substituted 
in its stead. 

In the non-inflammatory form, the protective bandage will 
be the best local application, unless there should be very severe 

* Some chemists are accustomed to add a few drops of sulphuric acid to the solution 
which appears to render it highly irritating to some eyes.— Wells, 



l62 PRACTICE OF MEDICINE. 

ciliary neuralgia, when it should be combined with the diligent 
use of atropine. If this fails to relieve, warm water compres- 
ses, of a temperature slightly above that of the blood, may be 
used in connection or in alternation with the bandage until the 
pain is moderated, when the compresses should be omitted, as 
their continued use would aggravate both the conjunctival and 
corneal inflammation, and also tend to increase the suppurative 
process. 

If the case should become indolent, either warm or hot 
fomentations will be required, according to the degree of pas- 
sive congestion or vascular stasis then existing, the object 
being to excite just sufficient inflammatory reaction to promote 
resolution, but no more. This, it is evident, will call for the 
exercise of sound judgment, as well as the greatest care, on 
the part of all to whom their application is intrusted. If too 
long continued, or if the temperature is too high, the inflam- 
matory symptoms will be apt to pass the bounds of healthy 
reaction, in which case they will require to be subdued by cold. 

Ulceration is generally best treated by pressure, after the 
inflammatory process has been regulated by the local measures 
already recommended. The bandage should be elastic, like 
flannel, and long enough to pass twice round the head, so as 
to exercise the requisite pressure on the cornea. The pressure 
bandage is also frequently useful in limiting the extent of sup- 
puration, but, according to Graefe, is not applicable to those 
cases of rapid suppurative necrosis which sometimes succeed 
the sudden disappearance of acute symptoms. 

If, in spite of the foregoing treatment, suppuration still 
continues, especially if it threatens perforation, benefit will be 
derived from puncturing the cornea, (paracentesis,) not so much 
by the simple removal of the purulent infiltration, as this is 
rarely so fluid as to escape freely from so small an opening 
but rather, by diminishing intra-ocular tension, to promote 
absorption of the infiltration, and hasten the restoration and 
cicatrization of the corneal tissue. If the ulcer is compara- 



SUPPURATIVE KERATITIS. 163 

tively small, the operation may be performed with a small 
needle, such as is represented in Plate I, Fig. 10; but if 
the ulcer is a large one, or if it has opened into the anterior 
chamber and formed an extensive hypopyon, the incision 
should be made with a broader instrument, such as the ordinary 
lance-shaped knife, of what is better, Desmarre's stop knife, 
represented in Plate I, Fig. 15. {See Paracentesis Cornea). In 
order to empty the abscess entirely, it will generally be found 
necessary to carry the instrument into or through the bottom 
of the ulcer, and also to repeat the operation several times, at 
short intervals, as the opening made by the incision is usually 
soon obliterated. 

But paracentesis, as usually performed, is generally less 
effective than iridectomy, especially if the iris is involved, or if 
the ulcer or hypopyon is of considerable size. This operation 
not only acts beneficially upon the inflamed iris, but lessens 
more completely, and for a longer period, the intra-ocular pres- 
sure, and thereby exerts a greater influence in diminishing the 
corneal suppuration, in promoting absorption of the infiltration, 
and in facilitating the regeneration of the corneal tissue. (See 
Iridectomy). 

Another operation, called Saemisches, has more recently 
been introduced, which consists in a free transverse section of 
the cornea, after the manner of operating in cataract. This 
operation is especially suited to the non-inflammatory form, in 
which the necrosis takes place superficially, or towards the cir- 
cumference, and which may or may not be complicated with 
iritis or hypopyon. The operation consists in laying open the 
base of the ulcer with a Graefe's cataract knife, (PI. II. Fig. 34), 
the eyelids being separated with the stop speculum, (Fig. 33). 
The point of the knife is entered on the temporal side, about 
one millemetre from the margin of the ulcer, and having 
penetrated the anterior chamber the blade, with its edge turned 
towards the bottom of the ulcer, is carried through the chamber 



164 PRACTICE OF MEDICINE. 

behind the ulcer, the counter-puncture being made at a cor- 
responding point on the opposite side of the cornea, and just 
beyond the margin of the ulcer. The fixing forceps, (PL II., 
Fig. 36), with which the globe has been steadied, are now laid 
aside, and the knife is made to cut its way out through the bot- 
tom of the ulcer, being so managed as to allow the aqueous 
humor to escape gently beside the blade, and with it any coex- 
isting hypopyon. The eye is then covered with a light com- 
press, and afterwards treated with Atropine. The success of the 
operation, according to Saemisch, has been of the most gratify- 
ing character, the progress of the disease having been imme- 
diately arrested in almost every instance. 

With respect to the general treatment of corneal ulcers, we 
should be guided to a considerable extent by general principles. 
Thus, if the degree of local inflammation is excessive, we should 
aim to subdue it without going to the other extreme, which 
would favor the disintegrating process, and at the same time 
hinder the filling up of the ulcer. The remedies best adapted 
to fulfill these opposite conditions, can be best selected accord- 
ing to the law of similia, choosing such as correspond both to 
the general constitutional condition and to the pathological 
state of the cornea. The inflammatory process is so intimately 
related to the suppurative, that, so far as medicines are con- 
cerned, the chief aim should be to regulate it, neither attempt- 
ing to subdue it altogether, nor on the other hand, allowing it, if 
excessive, to go on uncontrolled. It follows, therefore, that such 
remedies as Aconite, Belladonna, Cactus, Digitalis, Gelsemi- 
num, Mercurius, Tartar-emetic, Veratrum, etc., will be of frequent 
benefit, and may be prescribed agreeably to the indications al- 
ready pointed out. The same may be said of the ciliary irri- 
tation and neuralgia, which may be combatted with such reme- 
dies as Atropine, (used topically), Belladonna, Cimicifuga, 
Conium, Spigelia, etc., while the suppuration may be meas- 
urably controlled by Arsenicum, Hepar Sulphuris, Kali hydri- 



Vascular Keratitis. 165 

odicum, Lycopodium, Mercurius, Sulphur, etc. See Therapeutic 
Indications on page 621, Dec, 1876 ; and consult Tables XIV. 
XV. at the end of the Section on Ophthalmic Diseases. 

Diet and Regimen. — The fact that most cases of suppu- 
rative keratitis occur at the two extremes of life, and in delicate 
and weakly constitutions, will suggest the importance of mak- 
ing use, especially in non-inflammatory cases, of a liberal and 
nourishing diet, coupled if necessary with the milder stimulants 
such as wine, ale, porter, etc. Too much emphasis can not be 
laid upon the importance of pure air, cleanliness, and attention 
to the general health. The digestive and assimilative organs 
should be kept in the best possible condition, the secretions, 
particularly those of the bowels and skin, should be carefully 
regulated, and in fine every suitable means should be taken to 
cleanse, invigorate and build up the system. 



3.-VASCULAR KERATITIS. 

KERATITIS PANNOSA. 

SYMPTOMS. — Vascular keratitis is chiefly characterized 
by a development of vessels on the surface of the cornea. 
The membrane first becomes more or less opaque, loses its 
brilliancy and polish, and not unfrequently appears sandy, as if 
dotted over with a multitude of extremely fine points. (See 
Fig. 8) Vessels afterwards begin to show themselves upon 
the surface, advancing towards the centre, and becoming more 
and more numerous as the opacity increases, until finally the 
cornea is over run with a fine vascular net work called pannas, 
(Keratitis pannosa). Occasionally the vascular turgescence is 
so great as to cause a rupture of some of the vessels, giving 
rise here and there to extravasations of blood, which appear as 
small ecchymosed spots in the interstices. The deeper por- 
tions of the cornea generally remain unaffected. 

Vascular keratitis, like other forms of corned inflamma- 



[66 PRACTICE OF MEDICINE. 

tion, generally begins with more or less ciliary irritation, which 
proceeds, sometimes for days, the opacity of the cornea. This 
is accompanied with conjunctival and episcleral injection, the 
corneal and circum-corneal zones being generally well-marked. 
(See Fig. 8.) When the inflammation is severe, the surround- 
ing parts participate more or less in the inflammatory process, 
the conjunctivae and lids becoming red and swollen,and are accom- 
panied in some cases with a marked elevation of temperature. 

The pain is frequently extreme, especially when the nerve 
fibres are exposed by the shedding of epithelium, or by excoria- 
tion. In these cases there is generally severe photophobia, 
with lachrymation and spasm of the lids ; sometimes, however, 
there is little or no pain accompanying the photophobia, and 
vice versa, even when associated with spasmodic contraction of 
the pupil. 

The duration of the disease varies considerably, according 
as the cause is temporary or lasting. In the one case it may 
run its course in a few days, while in the other, even under the 
best treatment, it may continue for many weeks. 

Etiology. — The chie/ causes are such as produce mechani- 
cal irritation of the corneal surface, especially trachoma, invert- 
ed cilia, dust, cinders and other foreign bodies. Besides these, 
other deleterious external influences, such as heat, smoke, steam, 
irritating collyria, salves, caustic fluids, sudden changes of tem- 
perature, and even long exposure to air 1 itself, as in ectropion, 
sometimes induce it. The vascularity may also result from the 
excitement of active inflammation in neighboring parts, as in 
the different forms of conjunctivitis. It is also an accompani- 
ment of other forms of keratitis, especially the phlyctenular. 
Finally, it may owe its origin in some cases to internal causes, 
either pathological or functional, especially such as give rise to 
protrusion of the globe, or to spasmodic pressure of the lids. 

PROGNOSIS. — This is generally favorable, as the causes 
producing it are such as may be usually, and in many cases, 



VASCULAR KERATITIS. 1 67 

speedily overcome. When the cause is not removable, of course 
the prognosis is bad, as then the pannus and opacity are likely to 
continue in spite of the very best treatment. On the other 
hand, many cases amenable to treatment are rendered tedious 
and difficult of cure, by reason of the long existence of the in- 
flammation, and the extent and character of the resulting 
opacity. Relapses are also common, and the utmost care is 
required on the part of both the surgeon and the patient to 
prevent them. 

TREATMENT. — The first, and in many cases the only treat- 
ment required, will be the removal, whenever possible, of the 
cause. Hence, misdirected cilia, or any foreign substance which 
may have found a lodgment in the conjunctival sac, should be 
carefully sought for and extracted. For the same reason, 
trachomatous elevations should be destroyed by caustics, the 
removal of which generally leads to speedy improvement. 

After remedying as far as possible the action of external 
causes, if the inflammation continues unchecked, and especially 
if there is much heat of the neighboring tissues, cold compresses 
should be applied until the vascular action is sufficiently reduc- 
ed, when additional benefit will be derived from the instillation 
of Atropine, and the application of a protective bandage. If 
these measures, aided by suitable internal treatment, fail to 
relieve the excessive ciliary neuralgia, photophobia and spasm 
of the lids, and especially if, as is generally the case, the patient 
h delicate or debilitated, such hygienic, dietetic and constitu- 
tional treatment should be adopted as will be best calculated to 
invigorate the general system. 

After the inflammatory and nervous symptoms subside, if 
the cornea still remains cloudy, or if the disease threatens to 
become chronic, the vascular stasis may be overcome by dust- 
ing the corneal surface once or twice a day with Mercurius 
dulcis. The calomel, which of course should be entirely free 
from all impurities or lumps, may be applied by insufflation, or 



l68 PRACTICE OF, MEDICINE. 

which is better, by means of a short camel's hair pencil, by tap- 
ping the brush, not too heavily loaded, immediately in front of 
the cornea. The remedy is generally well borne, but if not, it 
should be used less frequently, or else entirely omitted. 

Vascular keratitis, whether arising from trachomatous irri- 
tation, herpes corneae, or pannus, is often greatly benefitted by 
the operation called canthoplasty. This operation consists in 
dividing the outer canthus with a bistoury or pair of strong scis- 
sors. If the former is employed, the instrument (PL I, Fig. 30) 
is introduced upon a director, behind the external canthus, and 
is made to emerge near the orbital border. The commissure is 
then divided horizontally, that is, in the direction of the palpe- 
bral fissure. If the scissors are used, one blade should be pass- 
ed behind, and the other in front of the outer canthus, and the 
commissure divided as before. An assistant now causes the in- 
cision to gape by holding the lids widely apart, and the raw 
edge of the conjunctiva is united to that of the skin by means 
of two or three fine sutures, one of which should be at the upper 
and another at the lower angle of the wound. The operation 
as described is a perfectly safe one, and highly serviceable in 
allaying irritation of the cornea, by diminishing the friction be- 
tween it and the palpebral surfaces. 

The internal remedies best adapted to this affection, to- 
gether with their therapeutic indications, will be found on pages 
577 and 578 of this journal for 1876. 

Consult, also, Tables XIV and XV, and the TJierapeutic 
Indications at the end of the Section on Ophthalmic Diseases. 



PRACTICE OF MEDICINE. 1 69 

^.-PHLYCTENULAR KERATITIS. 

HERPES CORNER. 

SYMPTOMS. — Phlyctenular keratitis is principally charac- 
terized by the development of herpetic vesicles, or phlyctenulae, 
on the surface or in the substance of the cornea. The disease 
is frequently associated with phlyctenular ophthalmia, and is of 
the same nature, differing only in its seat and the consequent 
severity of the subjective symptoms. (See Phlyctenular Con- 
junctivitis}) 

The vesicles vary considerably in number, size and arrange- 
ment. Sometimes they are solitary, or nearly so ; at other times 
they are numerous, and scattered irregularly over the surface ; 
or they may be arranged in groups at or near the margin of the 
cornea, where they frequently form an arc of considerable ex- 
tent. Occasionally they are very superficial, appearing like 
beads of sweat just under the epithelium. Most commonly, 
however, they are larger and more deeply seated, having at first 
the appearance of little rounded tubercles, of a grayish or pearly 
color, imbedded in the superficial layer of the cornea, with their 
apices slightly raised above its surface. The portion of cornea 
immediately surrounding the tubercle is generally somewhat 
swollen, the puffed appearance being. due to a cloudy border of 
infiltration, which is most marked in places where the 
phlyctenulae are most closely aggregated. Sometimes a trans- 
parent vesicle forms on the summit of a tubercle, the bursting 
of which gives rise to a small ulcer, with a grayish, or grayish- 
yellow, base and well-defined edges. Occasionally the ulcer ex- 
tends at its circumference, at the expense of the cloudy border 
surrounding it, constituting what is called the resorption ulcer. 
Sometimes no vesicle forms, and then the tubercle becomes 
denuded of its epithelium, and melts away, as it were, into an 
ulcer of corresponding dimensions. The phlyctenulae, and their 
associated tubercles and ulcers, do not all appear at once, but in 



I70 PRACTICE OF MEDICINE. 

successive crops, so that they may be seen in various stages of 
development at the same time. The ulcers when properly pro- 
tected generally heal readily, gradually filling up and becoming 
covered with epithelium.without, as a general rule, permanently 
impairing the transparency of the cornea. 

When the Phlyctenular are numerous and scattered, the 
conjunctival and episcleral injections are generally strongly 
marked, especially the rose-colored zone around the cornea ; 
but when confined to one side of the cornea, the hyperaemia is 
usually limited to the corresponding portion of the ciliary 
region. In this case the phlycten forms the apex of an irregu- 
lar vascular triangle, whose base is turned towards the circum- 
ference of the globe. As the eruption is situated exactly at the 
apex, and the vascular net-work extends at first only to the 
border of the cornea, if the vesicle happens to be seated at a 
distance from the corneal border, the vascular triangle will be 
incomplete, a clear or non-vascular portion of the cornea inter- 
vening between the eruption and the marginal cut-off. This 
appearance, however, is sometimes only temporary ; after a 
while the irritation developes vascular keratitis, and the vacant 
portion of the triangle becomes bridged over with a net-work of 
vessels, constituting what is sometimes called the herpetic bridge. 
When the vesicles are much scattered, each group or phlycten 
may be connected with a separate bundle of vessels, and these 
may so inter. ningle and overlap each other, as to destroy in a 
great measure their individuality. 

The disease is preceded and accompanied with more or less 
pain, heat, photophobia, spasm of the lids, and lachrymation. 
These symptoms vary greatly in different cases, and in different 
stages of the same case, being sometimes so intense as to be al- 
most intolerable, and at others so light as scarcely to attract at- 
tention. As a general thing, however, they are much more 
prominent and persistent then when the disease is confined to 
the conjunctiva. 



PHLYCTENULAR KERATITIS. 171 

ETIOLOGY. — The causes of phlyctenular keratis are as 
varied as they are numerous. Not only is it capable of being 
excited by external irritants, such as usually give rise to other 
forms of keratitis, but it is so frequently associated with a simi- 
lar eruption occuring in the course of the distribution of the 
trifacial nerve that many observers refer its origin in such cases 
to irritation of the ophthalmic branch of that nerve, or to ac- 
companying branches of the sympathetic. Another supposed 
cause is the scrofulous diathesis, the disease appearing most fre- 
quently in scrofulous children, and in persons of a feeble, irrita- 
ble and cachetic habit, (See Scrofulous Conjunctivitis) 

PROGNOSIS. — Notwithstanding the great tendency to re- 
lapses in this disease, and its consequent liability to become 
chronic, it frequently terminates in perfect recovery. When the 
phlyctenular are few and superficial, excoriations or ulcusles 
formed from them soon fill up, and under favorable circum- 
stances leave no trace of their previous existence. But the 
more deeply-seated tubercles rarely disappear altogether, but 
leave opacities of greater or less size, the effects of ulcers 
that may have existed for weeks or even months. Occasion- 
ally the history of the herpetic tubercle is still less favorable, 
the resulting ulcer extending deeper and deeper, and finally 
ending in perforation. Or it may undergo cartilaginous or 
calcareous degeneration, forming opacities of a dense and per- 
manent nature. Finally, the disease sometimes becomes com- 
plicated with iritis, trachomatous conjunctivitis and pannus 
with their attendant consequences. 

Treatment. — The treatment of phlyctenular keratitis is 
similar to that recommended for phlyctenular conjunctivitis and 
vascular keratitis, (which see p 610, 1876). The most important 
points are, the instillation of Atropine and the application of 
a protective bandage. The Atropine acts beneficially by 
diminishing ciliary irritation, and also by lessening intra-ocular 
pressure. The latter is of special consequence in the case of 



172 PRACTICE OF MEDICINE. 

deep ulcers, the floor of which may be so thin and weak as 
to render it unable to sustain the normal amount of pressure 
In case the Atropine is found to disagree, Belladonna collyrium 
should be substituted. In a few rare instances, owing to some 
peculiar idiosyncrasy of the patient, neither of these prepara- 
tions will be well borne, in which case their use will have to 
be abandoned. The protective bandage, however, is of uni- 
versal application. It effectually protects the ulcerated sur- 
face from contact with the air, which is always highly irritat- 
ing, not only to corneal ulcers, but to ulceration in every part 
and tissue of the body. It is likewise equally serviceable in 
allaying the ciliary irritation, pain, photophobia, and other 
sympathetic symptoms. The bandage may be made of flannel, 
and of sufficient length to extend twice around the head. The 
best way of applying it is to place a piece of fine muslin over 
the closed eye, and then to fill the orbital depression with fine 
charpie, so that the bandage may exert a uniform pressure 
upon the diseased organ. 

Other local measures, as well as the most appropriate 
hygienic and constitutional treatment, will be found under the 
two heads above referred to, and therefore need not be repeat- 
ed. (See Phlyctenular Conjunctivitis a?id Vascular Keratitis) 

ART. IV. — SCLERITIS. 

Although inflammation of the sclera is a very frequent 
accompaniment of conjunctivitis and keratitis, it is doubtful 
whether it ever occurs as a primary or idiopathic affection. As 
a secondary disease it is quite common, but its symptoms are 
so often masked by those with which they are associated, that 
they frequently escape observation. The inflammation is gen- 
erally partial, affecting only the anterior and superficial portions 
of the membrane ; but it is sometimes general and deep-seated, 
in which case -it is nearly always associated, perhaps always, 



EPISCLERITIS. 173 

with general choroiditis. It seldom leads to suppuration ; but 
sometimes portions of it undergo fatty degeneration, breaking 
down into fatty and purulent products, and nearly destroying 
the tissue. As commonly met with the disease occurs in two 
distinct forms, both of which are usually described under the 
head of 

EPISCLERITIS. 

SYMPTOMS. — Episcleritis, properly so called, is a partial or 
circumscribed inflammation of the anterior portion of the 
episcleral tissue. It is characterized by the appearance near 
the cornea of one or more small dusky-red spots, which as the 
disease progresses generally become more or less elevated and 
nodular, and of a deeper or somewhat purplish hue. These 
elevations are commonly situated near the insertion of the recti 
muscles ; most frequently near that of the external rectus. The 
conjunctival and episcleral injection, which usually precedes and 
accompanies the formation of the little tumors, is generally 
limited to their immediate vicinity, at which points the episcleral 
tissue is more or less infiltrated and swollen, the vessels distend- 
ed and vein-like, and the affected portion of the membrane of a 
dark, bluish or purplish color. 

The subjective symptoms are not generally very strongly 
marked, unless the cornea is implicated. As a general rule 
there is little or no pain, perhaps only a sense of uneasiness, 
though sometimes there is a dull, heavy, aching feeling in the 
eye, which renders the patient quite uncomfortable. Photopho- 
bia and lachrymation are more constant symptoms ; but, 
although sometimes considerable, they are often insignificant. 

At first the disease is liable to be mistaken for phlyctenular 
conjunctivitis, but the little tumor or nodule continues to in- 
crease in size, especially at the base, until it sometimes threatens 
to develope into what is called anterior sclerotic staphyloma ; but 
after existing for weeks, and perhaps months, it generally 
begins to diminish in size, and at last gradually dies away and 



174 PRACTICE OF MEDICINE. 

disappears. Or, it may recede only to return in the same or 
some other spot, and in this way the disease is sometimes pro- 
longed for an indefinite period. 

ETIOLOGY. — Very little is definitely known concerning the 
origin of this affection. Its frequent occurrence in young 
women has led some to infer that it is in some way connected 
with the menstrual function, but this is mere conjecture. It is 
perhaps most frequently met with in persons of a rheumatic or 
gouty habit. Its extreme obstinacy in subjects affected with 
syphilis, except when treated with anti-syphilitic remedies, 
renders it probable that it may sometimes owe its origin to that 
disease, especially when we consider how often syphilis affects 
other similar tissues. When occurring independently of other 
constitutional causes, it is probably due, in most cases, to over- 
work, debility, or some other depressing influence. 

PROGNOSIS. — This is almost always favorable. If, how- 
ever, the disease goes on uncontrolled, or if resolution fails to 
occur, the tumors may suppurate, giving rise to small abscesses 
in the sub-conjunctival tissue ; or they may degenerate, becom- 
ing cartilaginous or calcareous ; or, finally, deep-seated ulcera- 
tion may occur, resulting in anterior sclerotic staphyloma, or 
prolapse of the uvea. 

TREATMENT. — Little treatment is generally necessary, 
provided the patient will abstain from using the eyes, and will 
protect them from bright light by wearing a shade. The instil- 
lation of Atropine at night, and the use of warm fomentations 
when necessary, will generally relieve the ciliary neuralgia, 
which is not often very severe. Caustic collyria not only do no 
good, but frequently do harm by increasing the ciliary irritation. 
Wells, however, strongly recommends a weak collyrium of 
chloride of zinc, beginning with one-half grain to the ounce of 
water, and if well borne, increasing the strength to one or two 
grains to the ounce. When syphilis is at the bottom of the 
trouble, Kali hydriodicum is by far the best constitutional 



IRITIS. 175 

remedy, though good results have been obtained in these cases 
from Mercurius protoiodatus. Colchicum is generally the best 
remedy for rheumatic and gouty subjects, Bryonia being most 
serviceable for aggravations resulting from fatigue. Sepia is 
particularly useful when the catamenia are deranged. Nux 
vomica is a good remedy when the disease is induced or aggra- 
vated by over-taxing the eyes, especially when there is debility 
of the digestive organs or constipation. 

Diet and Regimen. — Whatever benefits the general 
health is likely to have a salutary influence on the disease. The 
diet should therefore be liberal, nutritious and easily digestible. 
The several animal functions, especially those of digestion and 
secretion, should be carefully regulated ; and the patient should 
take regular but moderate exercise in the open air. 

• • ART. V. — IRITIS. 

Ophthalmic writers have divided iritis into numerous forms 
or varieties, distinguishable for the most part by the special 
causes which are supposed to give rise to them. Thus, we have 
the simple or rheumatic, the arthritic, the gonorrhoeal, the 
syphilitic, the serous or cedematous, the suppurative or 
parenchymatous, the idiopathic, the sympathetic, the traumatic, 
etc. We may, however, reduce them all to the following four 
groups: (1), simple iritis ; (2), serous iritis ; (3), suppurative 
iritis ; and (4), syphilitic iritis. 

l.-SIMPLE ACUTE IRITIS. 

SYMPTOMS. — The principal symptoms of simple acute iritis 
are : Episcleral redness, pain, Iachrymation, photophobia, 
chemosis, structural changes lin the iris, sluggishness or immo- 
bility of the pupil, and more or less febrile disturbance of the 
system. 

The characteristic redness is due to sub-conjunctival or 
episcleral injection, in the form of a narrow band or zone, 



176 PRACTICE OF MEDICINE. 

immediately around the cornea. This zone, commonly called 
the corneal zone or circle, is composed chiefly of deep-seated 
arterial twigs, of a rose-red, or violaceous hue, straight and 
arranged parallel to each other, commencing at the junction of 
the sclerotica with the cornea, becoming finer and finer as they 
radiate from the latter, and terminating about a line from the 
corneal border. The vascularity of the conjunctiva is in some 
cases confined to the palpebral portion of the membrane ; in 
others the ocular conjunctiva is involved, the distended vessels 
proceeding from the circumference of the globe, following an 
irregular but nearly parallel course towards the cornea, and 
dividing into numerous branches, are at length lost in the nar- 
row, but deeper-seated, more constant and characteristic circle 
of vessels situated immediately around the cornea. The con- 
junctival vessels are readily distinguishable from those compos- 
ing the corneal zone, by being of a deeper red color and of 
larger calibre, by being displaced by the movement of the con- 
junctiva, by their more or less irregular distribution, and by 
their connection with other similar vessels coming from the 
palpebral surface. The episcleral redness is much more evenly 
diffused than the conjunctival, owing to the fineness, closeness 
and parallelism of the vascular injection. It is generally limit- 
ed, at first, to the corneal border ; but as the disease progress- 
es, the injection frequently becomes deeper and more general, 
until, in some cases, the entire surface of the subjacent sclera 
presents a reddish or rose-carmine appearance. Occasionally, 
however, we meet with severe cases in which the subconjunc- 
tival injection is but feebly developed, as in pyaemia, typhus, 
puerperal, and other low forms of fever. 

Some degree of chemosis of the ocular conjunctiva is gen- 
erally present, and this may be so great as to cause considerable 
bulging of the conjunctiva around the cornea. The eyelids also 
participate in the affection, especially the upper lid, which fre- 
quently becomes more or less inflamed and cedematous, when- 



SIMPLE ACUTE IRITIS. 1 77 

ever the attack is severe. These complications, however, are 
frequently absent. 

The pain, also, which is occasionally throbbing, and ac- 
companied with a feeling of distension or pressure, is sometimes 
almost entirely wanting ; but in most cases it is severe, often 
extremely so, and of a lancinating, burning or aching character. 
When confined to the eye it is generally superficial, but as the 
inflammation spreads the pain augments, and extends to the 
orbit, temple and side of the head. It undergoes frequent exa- 
cerbations and remissions, chiefly of a periodical character, and 
is always most severe during the night. So long as the inflam- 
mation is confined to the iris, the globe is not particularly pain- 
ful to the touch ; but when it extends to the ciliary body, con- 
stituting cyclitis, there is more or less tenderness and pain in 
the ciliary region. 

At first the eye is preternaturally dry, but soon the lachry- 
mal secretion is re-established, and becoming excessive, consti- 
tutes the condition called epiphora. This hyper-secretion,which 
is due to the sympathetic influence of the inflammation on the 
lachrymal gland, sometimes becomes so great as to overflow 
the lids. The tears are frequently hot and burning, particularly 
if there is much co-existing inflammation of the neighboring 
parts, and so irritating as sometimes to inflame the skin over 
which they flow. 

Photophobia is another prominent symptom of acute iritis, 
especially if the cornea is implicated, and is generally in propor- 
tion to the violence of the inflammation. The eye is unable-to 
bear the full light of day, and suffers more or less when expos- 
ed to a diffused light ; hence the patient generally keeps the 
eyes closed or deeply shaded. 

The constitutional disturbance, though modified to some 
extent by the age and health of the patient, commonly varies 
in proportion to the amount of local disorder. When severe 
there is generally considerable febrile excitement, which is 

23 



178 PRACTICE OF MEDICINE. 

sometimes accompanied by more or less derangement of the 
digestive organs. 

Vision is always more or less impaired, and in mild cases 
this is sometimes the only symptom that attracts attention. 
Many causes contribute to this result. Sometimes it is chiefly 
due to haziness or opacity of the cornea, the membrane appear- 
ing as if dotted over with fine points of opaque matter, as rep- 
resented in Fig. 8. In most cases of simple iritis, however, 
the cornea remains unaffected, or at most is rendered only 
slightly hazy. Vision may also be affected by cloudiness of 
the aqueous humor, or by diffuse opacity of the vitreous, due 
to co-existent inflammation of the ciliary body, in which case 
the power of accommodation is also impaired. But the chief, 
or rather the most constant causes of impaired vision in iritis, 
are such as result from paralysis of the muscles caused by 
proliferation of tissue, from immobility of the iris, or from a 
greater or less amount of occlusion or obstruction of the 
pupil by inflammatory products. 

In all cases the pupil is rendered more or less sluggish. 
This is owing partly to hyperaemia of the vessels, but chiefly 
to plastic or serous exudations into, or upon the surface of 
the iris, whereby its motions are mechanically hindered. 

Contraction and irregularity of the pupil are characteris- 
tic symptoms, dependent upon exudations between the iris and 
capsule of the lens, giving rise to a greater or less amount of 
adhesion between them. These exudations may be so situated, 
or so minute, as to escape detection until the pupil is arti- 
ficially dilated, or is examined by lateral illumination, when 
we may discover the beads of lymph which tie it to the anter- 
ior capsule. The exudations coalesce as they increase in size, 
until in some cases the entire pupillary margin becomes 
adherent, constituting what is called annular synechia. This 
condition does not materially interfere with vision, as the 
centre of the pupil still remains clear ; but when the exuda- 



SIMPLE ACUTE IRITIS. 179 

tions invade the pupillary opening, a greater or less portion of 
its area is covered with lymph, and then, of course, vision is 
proportionally obstructed. 

The contraction and immobility of the pupil are always 
associated with more or less dullness and discoloration of the 
iris. These symptoms are all due to the same causes, namely, 
to hyperaemia and effusion, and are among the earliest signs 
of the disease. The iris in its natural state has a more or 
less bright, glistening appearance, which is changed by inflam- 
mation to a dull, lustreless aspect, as though the membrane had 
lost its vitality. In addition to this the color itself changes. Blue 
and gray irides become slate-colored or greenish, while brown 
and black irides change to a reddish-brown or cinnamon color. 
As such changes are sometimes only apparent, the affected 
iris should always be carefully compared with that of the sound 
eye, remembering at the same time that dullness and discolora- 
tion of the iris may be caused by cloudiness of the cornea and 
of the aqueous humor. 

ETIOLOGY. — The chief predisposing cause of simple iritis 
is the rheumatic or gouty diathesis. But the same form of 
iritis may occur independently of rheumatism in other parts of 
the body, and unassociated with the gouty or rheumatic consti- 
tution. In such cases, however, the same exciting causes gener- 
ally give rise to it, namely, exposure to sudden atmospheric 
changes, dampness, wind, cold draughts of air, etc., and hence, 
as there are no characteristic symptoms by which to distinguish 
one form from the other, it has been customary to call them both 
rheumatic. Simple acute iritis, though frequently of traumatic 
origin, is most generally 'secondary, inflammation originating in 
other parts being transmitted to it in consequence of the close 
anatomical or functional relation they sustain to each other. 
Hence we have found it to be frequently associated with various 
forms of ophthalmia, especially the purulent. On the other 
hand, also, as we have seen, acute iritis is frequently complicated 



180 PRACTICE OF MEDICINE. 

with inflammation of the neighboring parts, constituting what is 
frequently called rheumatic ophthalmia. 

Prognosis. — The prognosis in the great majority of cases 
is favorable. The disorder is often obstinate, owing to its fre- 
quent complication with other forms of ophthalmic inflamma- 
tion, the diathesis of the patient, atmospheric influences, etc. ; 
but sooner or later the inflammation undergoes resolution, and, 
unless complicated with more serious affections, such as unyield- 
ing posterior synechiae, the organ fully recovers. Of course, in 
traumatic iritis the prognosis will have to depend, in a great 
measure, upon the nature, extent and precise seat of the injury, 
and should therefore always be particularly guarded. 

DIAGNOSIS. — The diagnosis has already been given with 
sufficient accuracy. Iritis is distinguished from simple inflam- 
mation of the conjunctiva, with which it is sometimes 
confounded, by the injection being originally confined 
to the episcleral tissue ; by its pinkish or violaceous hue ; 
by its forming a narrow zone about the cornea 
composed of straight, deep-seated, parallel vessels, disconnected 
with those of the conjunctiva; by the epiphora, photophobia, 
and orbital and circumorbital pain ; by the dullness and dis- 
coloration of the iris by exudations of plastic lymph upon its 
surface or margin ; and by the contracted, irregular and slug- 
gish state of the pupil. Not unfrequently the points of some 
of the vessels constituting the corneal zone encroach upon the 
edge of the cornea, forming upon its border a small vascular 
circle, or segment, varying in breadth from one-eighth to three- 
eighths of a line ; this is supposed to constitute one of the 
differential signs of rheumatic iritis. 

RESULTS. — The chief results attending this form of iritis 
are : exudations upon the surface of the iris, or upon its margin, 
and in the pupillary aperture ; adhesions to the anterior capsule ; 
{posterior synechia) ; occlusion of the pupil ; and, when compli- 
cated with keratitis, the development of phlyctaena on the cor- 



SEROUS IRITIS. l8l 

nea : superficial ulceration resulting from their rupture ; 
and more or less opacity of the cornea arising from depositions 
upon the inner surface or between its laminae. (See Fig. 8.) 
Treatment. — The medical and surgical treatment of iritis 
is so varied, and at the same time is of such great importance, 
that we deem it best to defer its consideration until after the 
other forms of iritis have been described. 



2 -SEROUS IRITIS. 

DESCEMETITIS. KERATITIS PUNCTATA. 

SYMPTOMS. — This form of iritis is chiefly characterized by 
an increase of the aqueous humor, and by the absence of plastic 
exudations. Instead of the usually contracted state of the 
pupil, this aperture is generally more or less dilated, in conse- 
quence of the increased intra-ocular pressure. Discoloration of 
the iris is not very perceptible, nor are the other symptoms of 
acute iritis sufficiently marked to attract attention. Pain and 
photophobia are generally absent, and the injection is usually 
limited to the vessels composing the narrow circum-corneal 
zone of the episcleral tissue. The aqueous humor is more or 
less turbid, the cloudiness arising from minute particles of float- 
ing lymph in the anterior chamber. Similar particles are de- 
posited in the form of points upon the posterior surface of 
the cornea, from which they occasionally project, giving to that 
membrane a punctated appearance, (keratitis punctata). Inter- 
stitial opacities also occur in the different layers of the cornea, 
especially of the posterior laminae, similar in appearance to 
those observed on the posterior wall of Descemet's membrane. 
These, however, are supposed to be caused by inflammatory 
changes, and not by deposits from the aqueous humor. Vision 
is always more or less impaired, owing partly to cloudiness of 
the cornea and aqueous humor, partly to intra-ocular tension 
caused by hypersecretion of the aqueous, and sometimes of the 



1 82 PRACTICE OF MEDICINE. 

vitreous humor, and partly to deeper seated inflammation, es 
pecially cyclitis and choroiditis, with which it is frequently as- 
sociated. 

ETIOLOGY. — Anaemia, chlorosis, scrofula, and especially 
syphilis, both constitutional and hereditary, have all been re- 
garded as predisposing causes. It is often observed in children 
affected with the peculiar notching of the central incisors, of the 
second dentition, which indicates congenital syphilis. It also 
constitutes one of the forms of sympathetic ophthalmia. 

PROGNOSIS. — Serous iritis is usually very chronic, but is 
generally less serious than either the suppurative or the syphili- 
tic. When timely recognized, if the affection which causes it 
can be overcome, the disease will generally soon disappear. On 
the contrary, if the deep structures of the eye have become im- 
plicated, and especially if there is at the same time a syphilitic 
dyscrasia to contend with, the prognosis is particularly bad. 

Treatment. — This we shall defer until we come to con- 
sider the treatment of the other forms of iritis. 



3-SUPPURATIVE IRITIS. 



SYMPTOMS. — Suppurative or parenchymatous iritis is 
characterized by the presence of pus-cells in the stroma or 
tissue of the membrane. In some cases their situation corres- 
ponds to the course of the vessels ; in others they coalesce and 
form small collections, constituting true abscesses. These find 
their way to the surface, either by ulceration or rupture, and 
sinking to the bottom of the anterior chamber, form an hypopyon. 
Generally, however, the exudation takes place on the surface of 
the iris, either in the form of a thin gray secretion, covering the 
iris like a veil, or else thick and puriform, interpersed here and 
there with minute patches of extravasated blood. The tissues 
of the iris swell and impede the circulation, and soon large 
varicose veins become visible on its surface. 

Neoplastic exudations also take place along the edge and 



SUPPURATIVE IRITIS. 1 83 

into the area of the pupil, as well as upon the posterior surface 
of the iris, giving rise to extensive adhesions between it and the 
anterior capsule. Frequently the deposits assume the form of 
irregular masses, or nodules, especially around the pupillary 
opening, where they sometimes give rise to annular synechias, 
or by extending into the area, fill up and completely occlude 
the pupil. Occasionally some of these nodular masses become 
detached, and melting down become mixed with the aqueous 
humor, and render it more or less turbid. The particles of 
disintegrated lymph and the pus globules, thus liberated, 
gradually settle to the bottom of the anterior chamber. The 
hypopyon thus formed is sometimes so small as to be seen 
with difficulty, appearing only as a narrow, yellow line along 
the floor of the anterior chamber ; in other cases it reaches 
the level of the pupil; and in some rare instances it fills the 
whole chamber of the aqueous humor. 

According to Von Graefe and other authorities, these col- 
lections of puriform matter are not always entirely due to in- 
flammation of the iris, some portions of them being derived 
from the membrane of Descemet, and some from the ciliary 
muscle, which is occasionally affected with the same form of 
inflammation. Suppurative iritis may also be complicated with 
choroiditis, constituting irido-choroiditis, one of the forms of 
sympathetic ophthalmia, (which see). 

ETIOLOGY. — As suppurative iritis is generally the result of 
a higher grade of inflammation than the simple, it follows that 
the same causes in some instances give rise to it. It is rarely 
the case, however, that catarrhal and traumatic iritis take on the 
suppurative form ; and when they do, it is generally by the ex- 
tension of the disease from other parts. On the other hand, it 
is not unfrequentlythe result of the continuation of the suppura- 
tive process from parts which are in anatomical or functional 
relation with it, as in keratitis and choroiditis. In other cases, 
again, it seems to depend upon certain constitutional affections, 



1 84 PRACTICE OF MEDICINE. 

especially syphilis. According to some authorities, it is occa- 
sionally due to a neurotic condition caused by malaria, in which 
case it assumes the intermittent form. That it may be caused 
by an irritative condition transmitted through the nervous 
system, has been established by the testimony of many recent 
observers. In this case it generally assumes the form of an 
irido-choroiditis. (See Sympathetic Ophthalmia}) 

PROGNOSIS. — Suppurative iritis is generally a much more 
serious affection than either simple or serous iritis, in conse- 
quence of the greater amount of neoplastic formations associat- 
ed with it, and which frequently give rise to extensive posterior 
synechias that effectually resist the action of Atropine. More- 
over, the disease is much more apt to be complicated with de- 
structive changes in the cornea, and also in the deeper-seated 
tissues of the eye. In these cases, of course, it is the complica- 
tions and sequelae, rather than the iritis, which often renders the 
prognosis doubtful, as the tissue of the iris may recover its 
normal condition, and yet its function, as well as that of the 
eye itself, may remain greatly impaired, or even be entirely de- 
stroyed. 

Treatment. — This will be given in connection with that 
of syphilitic iritis, (which see). 



4.-SYPHILITI0 IRITIS. 



SYMPTOMS: — Syphilitic iritis is characterized by the pro- 
duction of true gummy tubercles {gummata syphilitica), originat- 
ing in the stroma of the iris, and projecting above its surface in the 
form of condylomata or warts. They are often solitary, or nearly 
so; but occasionally they are more numerous, and either scat- 
tered about over the surface of the iris, or collected into a ring 
upon its pupillary or ciliary border. The tubercles vary in size 
from that of a millet seed to a split pea, their apices sometimes 
extending to the posterior surface of the cornea. They are 



SYPHILITIC IRITIS. 1 85 

mostly of a reddish or copper-colored tint, suggestive if not 
characteristic of their syphilitic origin. In this respect, how- 
ever, they vary considerably, according to the natural hue of 
the iris. Thus, in light irides, they are generally of a yellowish- 
red or cinnamon color, while in dark irides they are commonly 
of a dull reddish or muddy brown. They also become darker by 
age. 

The subsequent condition of the tumors varies according 
to circumstances. Sometimes they are rapidly absorbed ; at 
other times they undergo fatty degeneration and purulent solu- 
tion, the detritus mixing with the aqueous humor. Occasion- 
ally, on the other hand, after passing through certain 
metamorphic processes, they assume a more or less permanent 
form, as we shall see hereafter. 

The inflammatory changes in the iris are most marked in 
the vicinity of the tuberculous nodules, and as these are often 
confined to a particular portion of the membrane, the thicken- 
ing and vascularity of the iris are greatest at that point. This 
feature of the disease, like that of the gummy tumors on which 
it depends, is a peculiarity of syphilitic iritis. 

Although the appearance of gummy tubercles in the iris is 
an almost certain indication of their syphilitic origin, yet it 
is generally conceded that their presence is not necessarily 
connected with secondary syphilis ; nor, on the other hand, 
does their absence establish the non-syphilitic character of the 
affection. It is well to remember, therefore, that while the 
existence of gummy tubercles may be regarded as satisfactory 
evidence of the syphilitic nature of the inflammation, the dis- 
ease may have an undoubted syphilitic basis, and yet appear 
in the simple idiopathic or suppurative form. 

Diagnosis. — As there are no local symptoms sufficiently 
characteristic to establish beyond a doubt the syphilitic nature 
of the affection, it follows that it can only be positively de- 
termined by the existence of constitutional syphilis. Thus, 



1 86 PRACTICE OF MEDICINE. 

the specific character of the disease may reveal itself by a 
co-existent papalar eruption, by the presence of syphilitic 
ulcers in the pharynx, by enlargement of the lymphatic 
glands, or by the cicatrix of a chancre. In the absence of any 
of the peculiar evidences of constitutional syphilis, the history 
of the case, though it may not supply positive proof, may serve 
to elucidate the nature of the disease, or at least furnish prob- 
able grounds for suspicion. 

PROGNOSIS. — The prognosis in many cases of syphilitic 
iritis is most grave. Although the gummy tubercles are often 
quickly absorbed, they sometimes undergo permanent degener- 
ation, shrinking into hard nodules, or changing into tough, 
tendon-like masses, which either lie upon the surface or are 
buried in the stroma of the iris. In other cases, as we have 
seen, the suppurative process gives rise to formidable hypopya, 
many of which never entirely disappear, but leave behind per- 
manent products, which in some cases undergo fatty and cal- 
careous degeneration. In other cases, again, the deeper 
structures of the eye become involved, the disease finally ter- 
minating, it may be, either in atrophy of the globe or in 
panophthalmitis. 

TREATMENT OF IRITIS. 

The leading indications in the treatment of iritis are, first, 
to prevent, and afterwards, if necessary, to destroy or break up 
any adhesions of the iris to the anterior capsule ; (posterior 
synechia) ; to relieve ciliary irritation and neuralgia ; to lessen 
intra-ocular tension ; and to quiet the muscular action of the 
inflamed tissue. These indications are best met by the instil- 
lation of a strong neutral solution of Atropine (grs. ij — v. ad 
water gj), the free application of which produces complete 
dilatation of the pupil, sets the muscular fibres of the iris at 
rest by paralyzing the constrictor pupillae, and relieves the 
interior circulation of the eye, thereby diminishing congestion 



SYPHILITIC IRITIS. 1 87 

of both the ciliary body and iris. These results, however, can 
only be accomplished by the free and judicious use of the 
Atropine, as the inflamed, swollen and infiltrated state of the 
iris prevents, to* a great degree, its absorption, and also dimin- 
ishes its mydriatic effect, by producing stiffness and want of 
freedom of the muscular fibres of the membrane. It is there- 
fore advisable, and in most cases necessary, to apply the 
Atropine fifteen or twenty times during the day,or which is bet- 
ter, at intervals of only a few minutes, until it affects the pupil, 
so as to produce at once, if possible, sufficient dilatation to pre- 
vent adhesions and to set the membrane at rest. And should 
adhesions have already formed, the synechias if recent, narrow, 
or easily ruptured, may also by this means be broken through, 
and their reunion prevented, by keeping the pupil completely 
dilated. But this is not all ; the ciliary irritation and pain are 
generally greatly lessened, and in many cases entirely overcome, 
by the instillations, in which case nothing remains to hinder 
speedy recovery. 

But sometimes, owing to the peculiar state of the eye or 
the idiosyncrasy of the patient, the Atropine does not agree ; 
instead of lessening the ciliary irritation it seems to increase it. 
This result is most apt to occur when its influence upon the iris 
is resisted, the remedy not appearing to be absorbed sufficiently 
to produce its mydriatic affect, but, spending its action chiefly 
upon the ciliary region, greatly increases the hypersemia and 
irritability of the eye. In such cases the difficulty may often be 
overcome, and the best results obtained, by simply applying 
warm fomentations, the effect of which seems to be to relax 
the affected tissues and thereby favor the absorption of the 
remedy. In some of these cases the irritability may be allayed 
by substituting a collyrium of Belladonna in place of Atropine. 
at the same time rubbing in Belladonna ointment around the 
eye. 

Should the foregoing treatment fail in producing sufficient 



1 88 PRACTICE OF MEDICINE. 

dilatation of the pupil, a precious resource remains to us in 
paracentesis cornea. This operation not only favors absorption 
of the Atropine,but also lessens irritability of the eye, by dimin- 
ishing intra-ocular tension and relieving the internal circulation. 
The mydriatics will now be almost certain to act f ivorably, 
even in cases in which they had previously seemed to have lost 
their power. 

When extensive adhesions exist, it is well to bear in mind 
that if the Atropine does not quickly succeed in breaking them 
up, it is better to use them simply with the viewof allaying irri- 
tation and lessening intra-ocular tension, as a too energetic use 
of them under such circumstances serves only to fret the im- 
prisoned iris, and consequently to augment the inflammation. 
Should any doubt exist as to the inability of the iris to over- 
come the synechia, Calabar bean, which sometimes proves 
effective after Atropine has failed, may be tried. 

We have already suggested the use of warm fomentations, 
in case the Atropine fails to act on the pupil. Similar applica- 
tions, used as hot as they can be borne, and frequently changed, 
are equally beneficial in promoting absorption of recently 
effused lymph, and also of hypopyon. This remedy, simple as 
it appears, is invaluable in the treatment of both suppurative 
and syphilitic iritis. To be effective, however, the applications 
will require to be faithfully followed up. If for any reason this 
is found to be impracticable, heat and moisture may be applied, 
and the same end attained, by the use of hot emollient poultices, 
which should be changed every half hour or so, according to the 
severity of the case. These measures will not, of course, be 
required after the acute symptoms have subsided ; but the use 
of Atropine should be continued for several weeks, the object 
being to keep the pupil dilated and at rest. Unabsorbed 
hypopya will require to be removed by paracentesis. (See 
Paracentesis Cornea.) Other operative procedures will be con- 
sidered after we have given the 



SYPHILITIC IRITIS. 1 89 

THERAPEUTIC INDICATIONS. 

Aconite. — In the first stage of iritis, especially when the 
pupil is greatly contracted. Its usefulness is generally measur- 
ed by the acuteness of the symptoms and the earliness at which 
it is given. 

Arnica is most serviceable for nervous and plethoric 
patients, and when the iritis is of traumatic origin. • 

Arsenicum is one of our best remedies in serous iritis, 
especially in scrofulous subjects. It may sometimes be advan- 
tageously alternated with Kali hydriodicum. 

Belladonna is best adapted to cases attended with much 
conjunctival injection and swelling, especially when there is 
considerable ciliary neuralgia and photophobia. It is often 
alternated with Aconite, particularly at the commencement of 
the disease. 

Bryonia is especially suited to rheumatic cases, or when the 
eyeballs are sensitive to the touch or. on motion. It may be 
given in alternation with Aconite or Mercurius whenever these 
remedies are indicated. 

Chamomilla is useful in the iritis of scrofulous children, 
especially when characterized by severe ciliary neuralgia. 

Cimicifnga** is indicated when there is much pain and in- 
traocular tension. It is especially adapted to rheumatic cases. 

Colchicum is also indicated in rheumatic cases, especially 
when there is very great soreness of the eyeballs. 

Digitalis is another useful remedy in rheumatic iritis, es- 
pecially in the early stages, when there is contraction of the 
pupil and great tenderness of the globe, with more or less ach- 
ing in and around the eye. 

Kali hydriod. — This remedy is adapted to nearly every 
form of iritis, especially the serous and syphilitic. 

Mercurius. — This is, without exception, the most reliable 
general remedy for iritis, especially after exudation has taken 

* See Am. Horn. Obs., vol. 4, p. 229. 



190 PRACTICE OF MEDICINE. 

place. It is adapted to acute, sub-acute and relapsing cases ; 
also to those which become complicated with inflammation of 
other parts of the eye, particularly the cornea, ciliary body and 
choroid. 

Spigelia. — This is generally the best internal remedy with 
which to relieve ciliary neuralgia and photophobia. It is par- 
ticularly adapted to children, especially those of scrofulous con- 
stitutions. See " Additio7ial Therapeutic Indications" at the end 
of section on Ophthalmic Diseases. 

Diet and Regimen. — The diet should be simple and 
unstimulating. If the disease is chronic, or subject to frequent 
relapses, the patient will need to be particularly on his guard 
against everything calculated to favor hyperaemia and conges- 
tion, such as exposure of the eyes to bright light, wind, draughts 
of air, etc., or to straining them with reading, sewing, or any 
fine work. If necessary he should wear blue or smoke-colored 
glasses. (See NOTE, on page 129. 

OPERATIONS FOR ARTIFICIAL PUPIL. 

We have already passed in review the following circum- 
stances and conditions in which the operation for the formation 
of an artificial pupil is recommended : (1), permanent opacity 
of the cornea interfering with normal vision ; (2), permanent 
closure of the pupil, {atresia pupillce), either by contraction, 
occlusion, or complete posterior synechias of the pupillary mar- 
gin ; (3), suppurative keratitis, threatening extensive perfora- 
tion of the cornea ; (4), corneal perforation, and prolapse of the 
iris ; (5), to diminish intra-ocular tension ; and (6), to lessen in- 
flammatory symptoms. We shall also have occasion to recom- 
mend it in (7), glaucoma ; (8), staphylomata ; (9), cataract ; and 
(10), to facilitate the removal of foreign bodies from the 
aqueous chamber or iris. 

{a.) Iridectomy. — Of the numerous operations daily per- 
formed on the eye, this is both the most frequent and the most 
important. Being the safest and most successful operation for 



ARTIFICIAL PUPIL. I9I 

the formation of an artificial pupil, it has almost entirely super- 
ceded every other method. It consists in excising a small por- 
tion of the iris, after it has been drawn through an opening in 
the cornea made for that purpose. The instrument generally 
made use of for dividing the cornea is called a keratome. The 
blade is of a triangular or lance shape, and when the iridectomy 
is made on the temporal side, is set straight with the shaft ; 
(See PL I., Fig. 24) ; but when it is required to be made in- 
wards or upwards, the blade is bent to suit the plane of the 
nose and orbit. (Fig. 26). The forceps should for the same 
reason be straight, as in PL II., Fig. 36, or bent at an acute 
angle, as shown in Fig. 37. They should be so constructed that 
when closed the extremity will be perfectly smooth, so that 
they may be passed through the lips of the incision without 
lacerating them, or doing any injury to the iris. 

The operation is most conveniently performed as follows : — 
The patient having been placed upon a couch or bed, in a 
good light, with his head slightly raised, and chloroform ad- 
ministered to him by an experienced assistant, the operator 
places himself either behind or in Iront of the patient, as may 
be found most convenient, and having separated the lids to 
the desired extent by means of the stop speculum, (PL II., 
Fig"- 33)> an< 3 having fixed the globe by seizing the ocular 
conjunctiva with the fixing forceps, (Fig. 36), at a point exactly 
opposite where the incision is to be made, he takes either the 
straight or angular keratome, (PL I., Figs. 24, 26), as the case 
may require, and forces it in at the desired point, parallel 
with, and generally near to, the sclero-corneal junction, being 
careful to lay the handle of the instrument well back, so as to 
guide the point of the keratome into the anterior chamber in 
such a manner as to permit of its being safely pushed forward 
between the iris and cornea until the incision is of the requisite 
length. 

When the iridectomy is performed with the view of lessen- 



192 PRACTICE OF MEDICINE. 

ing intra-ocular tension, or for the purpose of relieving the in- 
terior circulation, as in iritis or glaucoma, or when there is but 
a limited space for the pupil on the margin of the cornea, the 
incision should be made in the sclerotica, about half a line from 
the corneal border, so as to penetrate the chamber exactly at 
the ciliary edge of the iris. But when it is intended for optical 
purposes only, the incision should be made through the cornea ; 
the preferable point being a little to the inner side of the centre, 
that being the direction of the visual ray. Other things being 
equal, however, the corneal opening should if possible be made 
near the superior border of the cornea, so that the upper lid will 
conceal to some extent the obliquity of the pupil, and at the 
same time reduce the amount of irregular refraction resulting 
from it: 

In withdrawing the keratome, care should be taken not to 
allow the aqueous humor to flow off too rapidly, otherwise the 
sudden reduction of the intra-ocular tension will cause conges- 
tion of the interior vessels, which may result in a greater or less 
amount of hemorrhage from rupture of the choroidal and 
retinal capillaries. In ^ase the incision made by the keratome 
is not sufficiently broad, or if, for any reason, it becomes neces- 
sary to widen it, it may readily be enlarged in either direction 
by an instrument designed for that purpose, represented in PL 
I., Fig. 20. 

On completing the section of the cornea as above describ- 
ed, if the iris does not protrude into the wound, the surgeon 
should pass the iris forceps, closed, through the lips of the 
incision, and having seized a fold of the iris, should draw it 
gently through the opening; and when a sufficient portion of it 
protrudes, the prolapsed part should be divided, either with a 
scalpel or bistoury, (PI. I., Fig. 22), or what is better a pair of 
iris scissors, (Fig's. 1, 18, 19). If on withdrawing the keratome 
the iris prolapses, there will of course be no necessity of enter- 
ing the anterior chamber with the forceps, but the protruding 



SYPHILITIC IRITIS. 1 93 

portion should be immediately seized, drawn out to the required 
extent, and then excised. 

(b.) Iriodesis. — This operation, consisting of an artificial 
prolapse of a portion of the pupillary margin of the iris, is 
often substituted for iridectomy in cases requiring simple dis- 
placement of the pupil. The general management of the 
patient, and the method of making the corneal incision, are 
the same as in iridectomy, except that the incision is always 
made near the border of the cornea. Sometimes the stop 
needle (PI. I., Fig. 15.) is used in making the corneal incision 
instead ot the keratome, in order to prevent the too sudden 
evacuation of the aqueous humor. After withdrawing the 
needle, a small loop of fine silk thread is placed directly over 
the opening in the cornea, and then a small blunt iris hook, 
bent at the proper angle, (PL I., Fig. 35, b.), is introduced 
through the loop into the anterior chamber, pushed forward 
until it catches in the proximal side of the pupil, which is then 
gently pulled out through the loop and tied by an assistant. 
The ends of the loop should cut off; but if the corneal 
incision has been made so large as to render the position of 
the prolapsed portion of the iris insecure, they should be 
cut long enough to be attached to the integument by means of 
a narrow adhesive slip. The loop will fall off in two or three 
days; if not it may be removed. If the operator chooses, he can 
make use of the canula forceps, (PI. I., Fig. 3.) instead of 
the hook for seizing the iris, and in many cases it is to be pre- 
ferred, especially when the pupil is required to be only slightly 
displaced. The operation, it is seen, is quite simple, but 
requires care in order to avoid separating the opposite border 
of the iris from its ciliary attachment. 

(c.) Iridenkleisis . — This operation is similar to the last. 
It consists in strangulating a portion of the pupillary margin 
of the iris in a long narrow opening made in the corneal bor- 
der of the sclerotica. The incision is generally made with a 

25 



194 PRACTICE OF MEtUCINE. 

keratome or lance-shaped knife (PI. I., Fig. 24.) precisely as 
in iridectomy, except that the instrument is entered very obli- 
quely three-fourths of a line from the corneal border, and 
only far enough to admit of the easy entrance of the canula 
forceps, (PL I., Fig. 3.) by means of which the iris is pulled 
out of the opening in the sclerotica, and there left. The stran- 
gulated portion generally drops off in a few days ; if it should 
not it may be removed. 

(d.) Iridotomy. — This operation consists in simply making 
an opening in the iris with a knife in cases in which, the lens 
being absent, the pupil closed, and the cornea clear, or if par- 
tially opaque, the opacity not interfering with the formation of 
an artificial pupil, one may be made by simply dividing the 
membrane. The operation may be performed either with a 
straight, spear-pointed, or lance-shaped knife, by passing the 
instrument through the cornea perpendicular to its surface, and 
after incising the iris to the required extent, immediately 
withdrawing it. The edges of the incision generally retract 
sufficiently to form a useful pupil ; but in case they do not, one 
of them may be drawn out with a blunt iris hook (PL I., Fig, 35) 
and excised. 

(e.) I rido dialysis. — This is a convenient method of forming 
an artificial pupil in cases where the central part of the cornea 
is opaque, or in which the only transparent portion is a narrow 
line at the circumference. The operation consists in entering 
the anterior chamber with the canula forceps, (PL I., Fig. 3), 
and separating a portion of the iris from its ciliary attachment. 
A better pupil may generally be obtained by first incising the 
cornea as in iridectomy, and then with the iris forceps or hook 
gently separating a small portion of the iris from its insertion, 
which is afterwards drawn out of the wound and cut off. 

(/.) Corelysis. — The object sought to be accomplished by 
this operation is the detachment of adhesions between the edge 
of the pupil and the anterior capsule of the lens, (posterior 



CYCLITIS. 195 

synechia). The latest and best method of operating is that 
devised by Passavant. which consists in introducing a pair of 
blunt-pointed iridectomy forceps through an incision in the 
cornea, ( See Iridectomy), seizing the iris between the senechia 
and the corneal opening, and gently drawing it towards the 
latter far enough to detach the adhesion. The operation should 
be repeated every two or three days until the entire pupillary 
margin is relieved. 

AFTER Treatment. — For several days after an operation 
for artificial pupil, the patient should be kept in bed, or re- 
clining quietly on a sofa, in a darkened room. All noise and 
excitement of every kind should be suppressed, and the patient 
kept in a state of complete mental and bodily repose. A pres- 
sure bandage should be immediately applied to both eyes, and 
drawn sufficientlytight to guard against intra-ocular hemorrhage. 
In a few hours the bandage may be loosened, but it should not 
be entirely removed for several days. After the operation of 
corelysis a strong solution of Atropine should be immediately 
applied, and the instillation repeated from hour to hour until 
the pupil is well dilated, after which the protective bandage 
should be applied, and so adjusted as to exercise just enough 
pressure to prevent winking. The diet for the first few days 
should be such as to require little or no mastication, consisting 
of such articles as milk, soft-boiled eggs, soups, etc. If much 
inflammation or ciliary irritation should set in, the treatment 
previously recommended should be rigidly enforced. 

ART. VI. — CYCLITIS. 

Inflammation of the ciliary body is seldom idiopathic. It 
is generally associated with its forerunner, iritis, constituting 
irido-cyclitis, or with iritis and choroiditis, forming irido- 
choroiditis. Sometimes the inflammation is transmitted to the 
ciliary body and iris from the choroid, and then we have what 
is called choroido-cyclitis or choroido -iritis. These combinations 



I96 PRACTICE OF MEDICINE. 

are readily understood, when we consider the similarity of 
structure and close anatomical relations of the parts involved, 
the iris, corpus ciliare and choroid constituting one continuous 
tissue, or tract, namely the uveal. Hence, inflammation 
beginning in one of these parts, is very apt to extend to the 
others, and vice versa. The disease presents two principal 
forms, or varieties, namely : (1) the serous, and (2) the purulent. 

1.-SEB0US CYCLITIS. 

SYMPTOMS. — Serous cyclitis is chiefly characterized by 
tenderness to the touch in the ciliary region, and by more or 
less intra-ocular tension, and impairment of vision. It is 
generally combined with serous iritis, the leading symptoms of 
which are : episcleral injection, ciliary irritation and neuralgia, 
increased tension, exudation of lymph upon the posterior 
surface of the iris, the veins of which are dilated and tortuous, 
enlargement of the pupil, and a greater or less degree of 
hypersecretion and cloudiness of the aqueous humor. In 
addition to these symptoms, irido-cyclitis is distinguished by an 
actual shallowness of the anterior chamber, due to a bulging 
froward of the floating portion of the iris, combined with an 
appearance of unusual depth, arising from a retraction of its 
ciliary margin, which is fastened by lymph to the ciliary body ; 
and the ophthalmoscope reveals large opaque spots scattered 
through it. Vision is always much impaired, and the field 
limited. The power of accommodation is also more or less 
affected. If the disease continues unchecked, it soon spreads 
to the choroid ; the aqueous humor, which at first was in 
excess, diminishes and becomes less than normal ; the tension 
also diminishes, so that the globe becomes soft ; and finally a 
condition of general atrophy ensues. 

The etiology, prognosis and treatment will be given under 
the head of 



PRACTICE OF MEDICINE. 1 97 

2.-PUBULENT CYCLITIS. 

SYMPTOMS. — The chief characteristic symptoms of purulent 
or suppurative cyclitis are : intense episcleral injection, severe 
ciliary neuralgia, photophobia and lachrymation, associated with 
pain and tenderness in the ciliary region ; occasionally, also, 
there is more or less cedema of the conjunctiva and lids. The 
iris is generally discolored, its ciliary margin retracted, and its 
veins dilated and varicose. Abscesses form in the ciliary body, 
and sooner or later purulent exudations take place from them 
into the anterior chamber, sometimes forming an hypopyon of 
very great size. 

ETIOLOGY. — The causes of cyclitis are : extension of 
inflammation from the neighboring tissues ; traumatic injuries 
of the ciliary body, especially those arising from operations on 
the eye. as in cataract ; and irritation resulting from adhesions 
of the pupillary margin to the anterior capsule. It also occurs 
in the form of "sympathetic ophthalmia," (which see.) 

PROGNOSIS. — Inflammation of the ciliary body, whether 
acute or chronic is always a very serious affection, especially 
the purulent form of it. Few cases, except the most recent, 
fully recover ; the tendency being to suppuration, atrophy, or 
chronic degeneration. 

Treatment. The indications being the same, irido-cyclitis 
calls for similar treatment to that already given under the head 
of iritis. If used early, hot fomentations, faithfully applied, 
will often give great relief, especially when the symptoms are 
acute; but to be effective they must be used early and 
assiduously, and even then they will sometimes fail in arresting 
the disorder. As soon as the fomentations have produced 
sufficient relaxation, atropine should be instilled, with the view 
of producing immediate dilatation. If, however, there is closure 
of the pupil, and especially if the deeper structures of the eye 
have become involved, no time should be lost in making an 
extensive iridectomy, provided there is no purulent exudation, 



198 PRACTICE OF MEDICINE. 

but it will not do to resort to this measure if there are any 
indications of suppuration. 

So far as internal treatment is concerned, the chief reliance 
must be on Merc, and Kali iod., with such other remedies as 
special symptoms may from time to time indicate. See 
Sympathetic Ophthalmia, Iritis, and Choroiditis. 

ART. VII. — IRIDO-CHOROIDITIS. 

The preliminary remarks made under the head of cyclitis, 
apply with equal force to irido-choroiditis, to-wit, that inflam- 
mation of any portion of the uveal tract ' may originate in the 
same, or in any other portion of it, and gradually spread 
through contiguous parts until the whole tract becomes involved. 
The same is likewise true respecting the various forms of 
inflammation to which each particular part is subject ; but we 
shall confine our attention at present to the consideration of 
the two principal varieties commonly met with in practice, 
namely : (1) simple or serous, and (2) pseudo-membranous irido- 
choroiditis. 

l.-SIMPLE IRID0-CH0B0IDITI3. 

SYMPTOMS. — This form of irido-choroiditis generally sets 
in with the usual symptoms of simple iritis, such as ciliary 
irritation and episcleral injection, abnormal appearance and 
discoloration of the iris, distension and varicose condition of its 
veins, sluggishness of the pupil, etc., to which is added, unless 
prevented by treatment, complete adhesion of the pupillary 
margin to the anterior capsule, {annular synechia), thus cutting 
off all communication between the anterior and posterior 
chambers of the aqueous humor. This closure of the posterior 
chamber necessarily destroys the balance of intra-ocular tension 
before and behind the iris, causing the latter to be pressed 
forward into the anterior chamber, either in the form of a 
circular cushion, or, as is more frequently the case, in the shape 



SIMPLE IRIDOCHOROIDITIS. 199 

of irregular knobs or, protuberances, due to the unequal resist- 
ance offered by different portions of its tissue. These knob- 
like projections are sometimes so extensive as to reach the 
posterior surface of the cornea, from which the pupillary margin 
of the iris suddenly recedes, giving to the central portion of the 
membrane a cup-like appearance, while the outer portion slopes 
gradually towards the circumference. If, now, an artificial 
communication be made between the two chambers, a yellowish 
watery fluid will flow out from behind the iris, the pressure 
upon the two surfaces will be equalized, the knob-like projec- 
tions will recede, and the membrane again resume its normal 
position. And since this will occur in whatever portion of the 
iris the iridectomy is done, it is plain that fhe irregularities are 
not due to plastic exudations on the posterior surface of the 
iris, but to an unequal distension of portions of its tissue, in 
consequence of an increase of intra-ocular pressure behind it 
arising from exclusion of the pupil. This exclusion, it will be 
remembered, may exist either with or without an open pupil, 
the only essential condition necessary to constitute it being an 
adhesion of the entire circumference of the pupil to the posterior 
capsule, so as to shut off all communication between the two 
chambers. (See Iritis) 

The tension of the globe varies greatly at different periods. 
At first it is generally normal, or nearly so ; then it is more or 
less increased ; afterwards, as the disease progresses and the 
inner structures become atrophied, the tension diminishes, until 
finally the globe becomes quite soft. 

If the pupil is in a condition to admit of an ophthalmoscopic 
view of the interior of the eye, the vitreous humor will generally 
be found to exhibit more or less cloudiness, mostly of a diffuse 
character, but here and there interspersed with flocculent tufts, 
and delicate leaf-like or moss-like opacities. Sometimes the 
cloudiness is most marked in the vicinity of the ciliary body, 
especially when there is extreme tenderness in the ciliary region ; 



200 PRACTICE OF MEDICINE. 

but usually the opacity is general, showing that the inflamma- 
tion has extended to both the ciliary body and choroid. 

The vision always becomes greatly impaired, even when 
the pupil remains unobstructed. At first there is a mere hazi- 
ness, which gradually deepens until the patient appears to be 
looking through a dense cloud. As the disease progresses, 
objects are seen with more and more difficulty, until finally the 
patient may be wholly unable to recognize them. 

The etiology, prognosis and treatment will be considered 
in connection with 

2.-PSEUD0-MEMBKAN0US IRIDO-OHOROIDITIS. 

SYMPTOMS. — This form of irido-choroiditis is characterized 
by the development of thick, tough masses of false membrane 
and plastic lymph upon the posterior wall of the iris and the 
anterior capsule, to the latter of which they adhere. The com- 
munication between the two chambers being thus cut off, the 
iris, and with it the lens to which it is attached, yielding to the 
intra-ocular pressure, is pushed forward into the anterior 
chamber, rendering it more and more shallow, until the pupil, 
which in these cases is not retracted, appears just behind the 
cornea. The iris is generally very much discolored, its fibrillar 
obscured, its tissue stretched, and its surface covered with large 
tortuous vessels, due to venous engorgement, the latter arising 
from obstruction of the circulation caused by inflammation of 
the ciliary body and choroid. 

The course of the disease varies according as the inflamma- 
tion begins in the iris or choroid. In the former case, the 
symptoms of iritis predominate. The episcleral injection of the 
corneal zone is generally well developed, and there is also more 
or less ciliary irritation and pain. The ocular conjunctiva 
frequently participates in the congestion, which is mostly of a 
venous character ; and, as in other cases of acute iritis, the 
palpebral conjunctiva and lids are apt to be more or less 



PRACTICE OF MEDICINE. 201 

swollen and inflamed. The iris is generally somewhat dis- 
colored, the pupil sluggish or immovable, and the aqueous 
humor sometimes cloudy or turbid. At a later period, the 
ciliary region becomes sensitive, and the vitreous humor more 
or less opaque, showing that the inflammation has reached 
the ciliary body. On the other hand, when the inflammation 
begins in the choroid, the first and most marked symptom is, a 
sudden and often very great loss of the power of vision, arising 
chiefly from diffuse opacity of the vitreous humor. Pain if 
present is not usually very great, nor is there generally much 
photophobia. The vascular injection of the superficial tissues 
is also very slight, and occasionally it is entirely absent. The 
retina generally becomes detached, in consequence of which the 
field of vision is more or less contracted. As the disease pro- 
gresses, the posterior portion of the lens frequently loses its 
transparency, and the ciliary region becomes sensitive and 
painful. Subsequently, as a general rule, the iris becomes 
discolored, and its veins tortuous and enlarged ; the pupil con- 
tracted, adherent, and more or less obstructed ; the aqueous 
humor cloudy and perhaps flocculent ; the anterior chamber 
greatly diminished by the bulging forward of the iris ; and the 
ciliary injection and neuralgia frequently augmented. The 
tension of the globe, which at first was somewhat increased, 
now begins to diminish, and unless the disease is speedily 
arrested, symptoms of atrophy and degeneration set in, the 
globe ultimately becoming soft, and vision extinct. These 
changes, though progressive, are often interrupted and irregular, 
being sometimes acute and rapid, at others slow, insidious and 
variable. 

ETIOLOGY. — The causes of irido-choroiditis are in many 
cases the same as those of iritis, the extension of the inflamma- 
tion to the ciliary body and choroid depending, in most 
instances, upon the location, extent, severity and duration of 
the irritation or injury ; and especially upon the presence of 
extensive posterior synechias, which, when complete or nearly 

86 



202 PRACTICE OF MEDICINE. 

so, lead to the frequent renewal of iritis, and to a gradual ex- 
tension of the inflammation to the other portion of the uveal 
tract. Sympathetic irritation may also give rise to it, as we 
shall find when we come to treat of " sympathetic ophthalmia." 

PROGNOSIS. — The prognosis differs very much, according 
to the character and extent of the pathological changes. It is 
only in recent and uncomplicated cases that we may reasonably 
expect to effect a satisfactory cure, or even to restore the vision 
to anything like a normal standard. On the other hand, if the 
disease is already of some standing, if there is complete 
adhesion of the pupillary margin to the anterior capsule, if 
large masses of false membrane exist between the iris and lens, 
and especially if extensive lesions of the choroid, opacity of the 
lens, or detachment of the retina has occurred, the prospect of 
cure is so slight as to render the prognosis very unfavorable. 
Some of these conditions, however, may be relieved ; and so 
long as the field of vision is good, and the sight but little 
impaired, the case cannot be considered altogether hopeless, 
even though a certain amount of atrophy has already taken 
place. 

Treatment. — Recent cases require no other treatment 
than that given under the heads of iritis, cyclitis and choroiditis, 
(which see). Those of longer standing will require that the 
operation of iridectomy shall be performed, perhaps repeatedly, 
both for the purpose of relieving intra-ocular tension, and of 
breaking up adhesions between the iris and anterior capsule. 
In pseudo-membranous irido-choroiditis this is extremely 
difficult to accomplish, partly in consequence of the shallow- 
ness of the anterior chamber and the rotten condition of the 
iris, but chiefly on account of the extent and firmness of the 
adhesions, which generally require the sacrifice of the lens. 
This, however, is of but little consequence in these cases, as 
both the lens and capsule are generally opaque. Von Graefe, in 
order to facilitate the operation, recommends the previous 



POST-FEBRILE OPHTHALMIA. 203 

extraction of the lens ; while Bowman performs what he calls 
"excision of the pupil," by cutting out with scissors a square 
portion of the iris, including the pupil, and afterwards removing 
it, along with the attached membrane, with forceps. If the lens 
is opaque, or if it is dislocated or wounded in the operation, it 
should be removed at the same time. These operations are 
very apt to excite fresh attacks of inflammation ; but neverthe- 
less it is necessary, in order to relieve the undue tension and 
prevent subsequent attacks of recurrent iritis, to re-establish 
communication between the two chambers at the earliest 
practicable moment. When this is satisfactorily accomplished, 
the vision often clears up in a remarkable manner, and even 
atropic symptoms, when not too far confirmed, are sometimes 
arrested ; the eye frequently regaining to some extent its normal 
condition and fullness. 

ART. VIII. — OPHTHALMIA POST-FEBRILIS. 

A peculiar form of irido-choroiditis, occurring in connec- 
tion with the so-called recurrent typhoid fever, and which has 
been referred to mal-nutrition and starvation, has been describ- 
ed by Mackenzie and other writers. We shall notice it briefly 
under the head of 

POST-FEBEILE OPHTHALMIA. 

SYMPTOMS. — This form of ophthalmia, which is generally 
confined to one eye, is characterized by inflammation of the 
iris and opacities of the vitreous humor. The disease does not 
usually manifest itself until several weeks after the last attack 
of fever has been subdued. The iritis is not generally very 
severe, seldom resulting in entire closure of the pupil, though 
frequently giving rise to scattered posterior synechias, and 
sometimes to hypopium. The adhesions are limited to the 
pupillary margin, and are generally easily overcome by the 



204 PRACTICE OF MEDICINE. 

energetic use of Atropine ; but the disturbances of vision, which 
in the latter stages arc chiefly due to purulent and flocculent 
opacities of the vitreous, frequently remain long after the more 
acute symptoms have been subdued. The disease, however, 
generally pursues a comparatively mild course; and, after lasting 
ten or twelve weeks, usually ends in entire recovery. It seldom 
attacks children under ten years of age ; but when it does, it is 
said to run a shorter, and in most cases a milder course, than 
when the patient is more mature. 

ETIOLOGY. — The chief cause is supposed to be an impov- 
erished state of the blood, resulting from mal-nutrition ; but the 
true nature of its connection with recurrent fever is not known. 
Some authorities attribute it to leucocythaemia, or an excess of 
white cells in the blood ; but, as Stellwag observes, this assump- 
tion is rendered very doubtful by the fact that the ophthalmia 
usually makes its appearance long after the last febrile attack, 
and, therefore, after the quality of the blood has become 
essentially improved. 

PROGNOSIS. — As already stated, the disease is seldom fol- 
lowed by any very serious consequences to vision, as the 
opacities are generally soon absorbed, and the synechiae can 
commonly be broken up. Cases complicated with hypopium 
are, however, more serious, and sometimes terminate in atrophy 
of the globe. 

Treatment. — We have already treated so fully of the 
remedial measures required in this disease, that to give them 
here would only be to repeat what we have said as to the 
therapeutic indications and local treatment of iritis, (which see). 

ART. IX. — OPHTHALMIA SYMPATHETICA. 

It has long been known that when one eye has become 
diseased, or has been severely injured, the other eye is liable to 
become sympathetically affected, especially if the causes or cir- 
cumstances which first give rise to the disorder are continued ; 



SYMPATHETIC OPHTHALMIA. 205 

but it has only been within a few years that sympathetic 
inflammation of the eye has attracted the attention which its 
importance demands. This form of inflammation is peculiar, 
since it does not follow operations for cataract or iridectomy, 
nor the loss of an eye from suppurative inflammation. The 
liability to the sympathetic affection appears to be greatest in 
cases in which the injured eye remains irritable and sensitive 
after recovery from the immediate effects of the accident ; as 
when a foreign body penetrates the eye, and, by remaining 
within it, keeps up a constant irritation, and finally excites 
sympathetic inflammation in the other eye. The affection thus 
excited is denominated 

SYMPATHETIC OPHTHALMIA. 

By " sympathetic ophthalmia " is understood a peculiar 
form of inflammation set up in a previously sound eye by an 
injury inflicted upon the other eye. It generally assumes the 
character of an insidious but malignant irido-cyclitis. In some 
cases the symptoms supervene within a short time of the inflic- 
tion of the injury; but in others the wounded eye appears to 
recover from the inflammation caused by the accident, and may 
continue in this condition for months without exciting any 
apprehensions of approaching danger, when fresh symptoms 
unexpectedly arise, the injured eye again becomes injected and 
painful, and soon the sound eye becomes sympathetically 
affected. This is especially apt to occur where the injury is 
caused by a bit of steel, or other metal, which, by remaining 
in the eye, afterwards sets up the usual suppurative process of 
elimination about the offending substance. In other instances, 
again, the wounded eye, especially if the injury happens to be 
in the ciliary region, instead of becoming quiescent, never fully 
recovers, but remains in a state of low inflammation, which 
greatly impairs the safety of the other eye. 

SYMPTOMS. — The symptoms vary considerably in different 



206 PRACTICE OF MEDICINE. 

cases. The most constant are : temporary disturbances of 
vision, accompanied with a gradual diminution of sight in the 
sound eye ; discoloration of the iris ; effusion of lymph upon 
its posterior surface and in the pupillary area ; adhesion of the 
iris to the anterior capsule ; exclusion of the pupil ; increased 
intra-ocular tension ; and, if not arrested, partial atrophy fol- 
lowed by softening of the globe. These symptoms are generally 
accompanied by more or less ciliary neuralgia, photophobia and 
lachrymation ; but in some cases there is neither orbital nor 
circum-orbital pain sufficient to attract attention, though the 
ciliary region is almost always sensitive to pressure. 
Occasionally, the disease manifests itself chiefly by amblyopic 
symptoms, either with or without photophobia ; and Von 
Graefe describes a rare form of the affection in which the retina 
is implicated. In these cases there is little or no pain ; the 
vision is greatly impaired, and the power of accommodation is 
almost wholly lost. The ophthalmoscope reveals congestion of 
the optic nerve ; the retinal veins are sometimes found to be 
dilated and tortuous ; and, in cases connected with increased 
hardness of the globe, especially such as occur in advanced life, 
there is frequently exhibited a glaucomatous excavation of the 
optic disc. 

ETIOLOGY. — The most frequent causes of sympathetic 
ophthalmia are : penetrating wounds in the ciliary region, 
especially such as are accompanied with loss of vitreous or 
wounding of the lens ; severe laceration or bruising of the eye, 
followed by ciliary irritation and unattended with general 
suppuration ; foreign bodies, such as chips of metal, glass, stone, 
etc., lodged within the eye ; intra-ocular hemorrhages ; con- 
traction, degeneration, or calcification of extensive fibrous 
deposits within the eye, especially when implicating the ciliary 
body ; and, when the stump remains irritable, the wearing of 
artificial eyes. In short, any injury which is capable of excit- 
ing prolonged irritation of the ciliary nerves, may give rise to 



SYMPATHETIC OPHTHALMIA. 20*J 

sympathetic irritation or inflammation of the other eye ; and, 
as stated by Wells, this is frequently found to occur at a spot 
of the ciliary region which corresponds symmetrically to that 
at which the injured eye was hurt, or at which the ciliary 
region still retains its sensibility to the touch. 

PROGNOSIS. — This is so unfavorable as to afford very 
little ground for hope after the disease has become fully estab- 
lished. It therefore becomes the imperative duty of the sur- 
geon to warn the patient in time of the very serious nature of 
his complaint, impressing upon him the fact that, notwith- 
standing the long period which may have elapsed since the 
original injury was received, and the apparently trivial character 
of his present symptoms, their presence constitutes an insidious 
source of mischief to the other eye, and that unless he speedily 
avails himself of the only effective treatment known to the 
profession, even that will prove unavailing, and vision will be 
surely and irretrievably lost. 

Treatment. — The most efficient, and, in the vast majority 
of cases, the only efficient treatment, either preventive or 
curative, consists in the early removal of the injured eye. Not 
that every considerable injury, even when involving the ciliary 
region, requires the loss of the injured eye in order to insure 
the safety of its fellow, for the observance of such a rule 
would cause many an eye to be needlessly sacrificed. But 
since no case of sympathetic ophthalmia is known to have 
originated after the injured eye has been removed, and since 
its removal generally arrests the disease in the other eye, when 
the operation is performed immediately after the latter becomes 
affected, it follows that if the power of vision is lost in the 
injured eye, and there is no prospect of its restoration, there 
can be no question as to the propriety of immediately enucleat- 
ing it. But the case is different if the sight continues tolerably 
good in the injured eye, or even if only a limited degree of it 
remains, especially if the sympathetic disease has already 



208 PRACTICE OF MEDICINE. 

made considerable progress, since the chances are that in these 
cases the injured eye will finally prove more serviceable to the 
patient than the other. Again, it may be regarded as an 
established fact, that the performance of any operation upon 
the affected eye during the height of the sympathetic disease 
not only fails in arresting its progress, but actually tends to 
increase it. No benefit, therefore, can be expected from 
iridectomy, unless it be performed at the very outset of the 
disease, before active inflammatory symptoms have set in, or is 
postponed until by treatment or otherwise they shall have 
measurably subsided. In the latter case, the operative 
measures indicated will consist in the performance of an 
extensive iridectomy, together with the removal of the lens, 
capsule, and adherent masses of exudation. Such an extensive 
operation will necessarily be attended with considerable 
danger, not only by directly increasing the inflammatory 
process, but by giving rise, in many cases, to profuse intra- 
ocular hemorrhage. " The weight of authority, therefore, 
especially in this country, is in favor of immediate enucleation, 
in preference to iridectomy or any other operative procedure, 
in all cases in which there is any doubt of a favorable 
termination. 

ENUCLEATION OF THE EYE-BALL. 

The removal of the eye-ball, which before the introduction 
of anaesthetics was regarded, even by the profession, as an 
operation of the most formidable character, has since been 
divested of all its terrors, and, under the improved method of 
doing it, will hereafter be considered as one of the most simple 
and trivial nature. 

The patient having been fully anaesthetized, the eyelids 
widely separated by the stop-speculum, (PL II. Fig. 33), and the 
globe steadied with a pair of fixing forceps, (Figs. 36, 37), the 
surgeon divides the conjunctival and sub-conjunctival tissues 
close to the edge of the cornea. He then introduces a stra- 



GLAUCOMATOUS IRIDO-CHOROIDITIS. 200, 

bismus hook (PI. I. Fig. 17) beneath the recti-muscles, one 
after the other, and divides them close to their insertion ; after 
which he carries a pair of curved scissors behind the globe and 
severs the optic nerve as far back as possible. The eye now 
springs forward from beneath the lids, and may be easily 
seized with the fingers and lifted from the socket, when the 
remaining muscles and conjunctival attachments are to be cut 
away, and the operation is finished. 

The hemorrhage, which ensues when the optic nerve and 
ophthalmic artery are divided, is generally soon arrested by 
injections of cold water ; if not, it may be readily controlled 
by placing a piece of sponge in the orbital cavity and apply- 
ing a compress and bandage. In the course of twenty-four 
hours, or sooner if the dressings are very painful, the sponge 
should be removed, and the orbit cleansed with a little tepid 
water, after which cold wet compresses should be applied for a 
few days, or until the discharges cease. The extremities of 
the severed muscles and optic nerve soon become covered over 
with a cicatrix composed of the contracted edges of the con- 
junctiva, and the stump thus formed is found to be well adapted 
for the adjustment of an artificial eye, the insertion of which 
need not generally be delayed more than two or three weeks 
after the performance of the operation. 



ART. X. — GLAUCOMATOUS IRIDO-CHOROIDITIS. 

The terms glaucoma and glaucomatous, signifying of a sea- 
green color, have been in use ever since the days of Hippocra- 
tes, by whom they were used to designate every form of deep- 
seated opacity. Afterwards they were limited to vitreous 
opacities and cataracts, which, occurring for the most part in 
advanced life, present a greyish or greenish appearance. Still 
later, the terms were applied to a particular form of oph- 
thalmia, which, as it occurs chiefly in gouty subjects, is some- 
times denominated arthritic. But since the invention of the 
ophthalmoscope, in 185 1, our knowledge of the internal 
diseases of the eye has been greatly advanced, the various 
pathological changes occuring in the choroid, vitreous, retina 
and optic nerve disc have been carefully studied and described, 
and as a consequence, the above terms are now used with much 
greater precision than ever before. By glaucoma, therefore, 
we no longer mean simply that condition of the globe which 
is marked by stony hardness with its associated symptoms, 



2IO PRACTICE OF MEDICINE. 

but also the previous abnormal conditions or diseases which 
give rise to it. We shall here treat only of the primary forms ; 
the secondary will be considered in connection with the 
diseases with which they are associated. 

1 -ACUTE INFLAMMATORY GLAUCOMA, 

ARTHRITIC OR VENOUS OPHTHALMIA. 

SYMPTOMS. — Premonitory Stage. — In by far the larger 
number of cases, the disease is preceded by certain premon- 
itory symptoms, such as repeated attacks of cephalalgia; 
neuralgia pains in the forehead and temples ; more or less 
venous congestion, which, however, is always slight during the 
premonitory stage ; indistinctness of vision, arising chiefly 
from disturbances in the circulation, and coming on periodi- 
cally ; the appearance of a colored halo, like a rainbow, around 
a flame, due probably to congestion ; dilatation and sluggish- 
ness of the pupil ; more or less cloudiness of the aqueous and 
vitreous humors ; and, occasionally, a slight variation in the 
field of vision. But the chief characteristic symptom, and 
that on which most of the above-mentioned signs depend, is a 
gradual increase in the tension of the globe, which, however, 
never becomes very considerable during this stage, and is some- 
times said to be entirely wanting. But this symptom is of 
such high importance, that whenever observed it should always 
excite our suspicions, especially if any of the before-mentioned 
signs co-exist. At the same time we should be on our guard 
against mistaking the subjective sense of tension or fullness 
within the eye for the objective sense of hardness, which may 
and often does exist without any real increase of tension. 

At first, and during the premonitory stage, these symptoms 
are more or less periodic, that is, they occur at intervals of 
longer or shorter duration, with a period of complete intermis- 
sion between them ; but sooner or later the intermissions cease, 
or are superceded by remissions only, certain symptoms belong- 



ACUTE INFLAMMATORY GLAUCOMA. 211 

ing to the disease remaining permanently, and constituting 
what is called 

Confirmed Glaucoma. — Glaucoma Evolutum or Con- 
firmatum. — After a longer or shorter duration of the 
premonitory stage — which in some cases lasts for years, 
although it generally extends over only a few months, 
and may even be limited to the first two or three attacks 
— the glaucoma breaks out suddenly, with symptoms of 
high inflammation ; the patient is seized with an intense head- 
ache and excruciating ciliary neuralgia, the pain shooting 
from the orbital and sub-orbital regions to the forehead, temple, 
face and occiput. The pain is always more or less remittent 
in its character, becoming greatly intensified on the approach 
of night, and is frequently accompanied with photopsy, or 
flashes of light. It is also frequently associated with cold or 
icy sensations, attended with a feeling of numbness, or anaes- 
thesia, in and around the affected eye, and in the corresponding 
side of the head. At the same time there is generally more or 
less febrile excitement, accompanied in some cases with nausea 
and vomiting. The eyelids are often red and swollen, the 
superficial tissues infiltrated and injected, and the veins greatly 
engorged. The vascularity bears a general resemblance to 
that of simple irido-choroiditis, but differs from it in the fol- 
lowing particulars. The corneal zone, while it has a similar 
disposition about the cornea, is composed of vessels exhibit- 
ing more numerous anastomoses, a deeper and more livid hue, 
and a sort of varicose enlargement ; but that which chiefly 
distinguishes the episcleral injection is a whitish or bluish-white 
ring, frequently more or less incomplete, and about the fourth 
of a line in breadth, which separates the vascular zone from 
the edge of the cornea, and called the venous circle. Some- 
times the chemosis is so great as to completely hide the 
episcleral vascularity quite up to the circumference of the 
cornea. The conjunctival injection consists of large vessels, 



212 



PRACTICE OF MEDICINE. 




ACUTE GLAUCOMA. 



tortuous and more or less vari 
cose, their trunks turned to- 
wards the great fold of the 
palpebral conjunctiva, and their 
K& branches ramifying by bifurca- 
tion ; those on the border of the 
cornea anastomosing here and 
there with branches from the 
other vascular trunks. (See 
Fig. p). There is generally con- 
siderable photophobia and lachrymation, but not much mucus 
discharge. The latter presents some peculiar features. In 
consequence of the frequent motion of the lids, the mucus 
collects on their edges, or in the angles and folds of the con- 
junctiva, in the form of white froth or foam ; this is the 
"arthritic foam" of the old authors. 

To complete the picture, the cornea becomes nebulous on 
its posterior surface ; the anterior chamber shallow, so that 
the iris is nearly or quite in contact with the membrane of 
Descemet ; the aqueous humor cloudy ; the iris more or less 
discolored ; the pupil dilated, irregular and sluggish ; the 
vitreous humor hazy and opaque ; and the globe abnormally 
hard. Vision is either entirely lost or greatly impaired ; in 
the latter case the field is generally contracted. As the 
inflammatory symptoms subside the blindness may continue, 
but this is not the general rule ; the sight may be fully restored. 
This, however, is only temporary. The acute inflammatory 
attacks continue to recur, the visual field becomes more and 
more contracted, and finally the sight is entirely lost. At the 
same time the globe becomes more and more tense, until 
finally it reaches a state of stony hardness. In other cases 
the inflammatory symptoms subside permanently, but still the 
eye does not recover its normal condition. The inflammation 
continues in a low form and becomes chronic ; the glaucomatous 



ACUTE INFLAMMATORY GLAUCOMA. 21 3 

degeneration increases more and more ; and finally all percep- 
tion of light, even quantitative, is lost. This state, called by 
way of distinction glaucoma absolutum or consummatum, is 
sometimes, but very rarely, reached within a few hours, and 
sometimes even within a few minutes, of the setting in of the 
attack. This last variety, known as fulminating glaucoma, is 
distinguished from the ordinary acute form by the rapid devel- 
opment of glaucomatous symptoms, especially by the sudden 
and complete destruction of vision, followed by atrophy and 
degeneration of the deep-seated tissues of the globe. 

The ophthalmoscopic symptoms, as well as the etiology, 
prognosis and treatment, will be given after the other forms 
of glaucoma have been described. 

2.-CHE0NI0 INFLAMMATORY GLAUCOMA. 

In our description of acute glaucoma we alluded to the 
fact, that after the subsidence of the acute attack, the disease 
frequently passed over into the chronic form. It may, how- 
ever, be developed insidiously from the prodromal or premon- 
itory stage. 

SYMPTOMS. — Chronic inflammatory glaucoma, when develo- 
ped from the acute, generally assumes at first a sub-acute form, 
at which degree it continues, with more or less decided exacer- 
bations and remissions, for a few weeks, after which the 
inflammatory symptoms become less and less conspicuous, 
while the glaucomatous process itself continues slowly to 
advance. Thus, the globe gradually becomes harder and 
harder, until at last it reaches the highest point of tension. 
(Tn. 3). The cornea becomes hazy, less convex, and more and 
more anaesthetic, until finally, in some cases, it loses all sensibil- 
ity. The sclera becomes atrophied and more or less translucent, 
assuming at last a peculiar waxy or porcelain tint. The 
episcleral veins are engorged and tortuous, the anterior cham- 
ber is narrowed by the pushing forward of the iris until the 



214 PRACTICE OF MEDICINE. 

latter almost rests upon the cornea, the aqueous humor is 
rendered cloudy or turbid, the pupil is dilated and either 
sluggish or immovable, and the iris loses its brilliancy, becom- 
ing more or less maculated and discolored. The diminution 
of sight generally keeps pace with these changes, and at the 
same time the field of vision becomes more and more contrac- 
ted. At last the sight is entirely destroyed, not even a trace 
of sensitiveness to light remaining. This state is generally 
characterized by a pale-greenish opacity of the lens, constitu- 
ting the so-called glaucomatous cataract. This symptom is 
not due, as is generally supposed, to degeneration of the lens, 
but to the combined effect of the mixing of the yellow color 
of the lens, peculiar to elderly people, with the bluish-grey 
color of the aqueous humor, which the latter assumes after it 
has become cloudy and turbid. The effect of this green reflex 
is somewhat heightened by the greyish opacity of the vitreous 
and the dilated state of the pupil. While glaucomatous 
cataract is generally due to changes developed in the course 
of the disease, it is not, as was formerly considered, an essen- 
tial, and consequently not a pathognomonic, symptom of 
glaucoma. 

Although absolute glaucoma may exist for a long period 
without any very striking changes in the symptoms, the above 
result is not generally reached without the recurrence, at longer 
or shorter intervals, of inflammatory attacks and exacerbations ; 
but these are usually of a low and insidious character, and 
are seldom attended, as in the acute form, with any very great 
amount of pain or suffering. Occasionally, however, acute 
inflammatory exacerbations occur, attended with headache, 
ciliary neuralgia, photopsy, etc.; and these may recur from 
time to time, either spontaneously, or as the result of external 
causes. At a later period the stage of atropic degeneration 
sets in ; the iris becomes greatly narrowed, and is reduced to a 
mere streak, the cornea is softened and rendered opaque, 



CHRONIC NON-INFLAMMATORY GLAUCOMA. 21 5 

hemorrhagic effusions take place in various portions of the 
globe, the choroid and retina degenerate, sclerotic staphy- 
loma are produced, followed, it may be, by suppurative 
inflammation and general atrophy. 

3.-CHR0NIC NON-INFLAMMATORY GLAUCOMA. 

GLAUCOMA SIMPLEX, OF DONDERS. 

Symptoms. — This form of glaucoma is chiefly character- 
ized by the absence during the earlier stages, and sometimes 
during nearly its entire course, of any appearance of inflam- 
matory symptoms. The only symptom that at first is apt to 
attract attention, is a gradually increasing weakness of vision ; 
and this, in the absence of other symptoms, is generally 
attributed to the approach of old age. The defect is most 
apparent for near vision, as in reading, writing, etc., though in 
many cases it is also well marked for distance. Owing to the 
absence of premonitory symptoms, the approach of the disease 
is generally very insidious ; and so quietly does it advance, 
that the patient is often unaware of his danger until after it 
has made considerable progress. Careful examination, how- 
ever, will generally detect an increase of tension in the weaker 
eye, accompanied with rapidly increasing presbyopia and more 
or less hypermetropia. As the disease advances the tension of 
the globe increases, the cornea loses its sensibility, the ciliary 
veins become congested, the pupil is sluggish and more or less 
dilated, the anterior chamber becomes shallower, the field of 
vision is progressively narrowed, and the sight more and more 
diminished, until finally all perception of light is extinguished. 
The disease seldom runs its course, however, without the acces- 
sion of inflammatory symptoms, which may be more or less 
violent according to the type of the inflammation. When 
acute, the symptoms of acute glaucoma will be superadded to 
those above-mentioned ; and in all cases there will be more or 
less ciliary neuralgia, cloudiness of the aqueous and vitreous 



2l6 



PRACTICE OF MEDICINE. 



humors, increase of intra-ocular tension, etc. These symptoms, 
however, may be so slight and transitory as scarcely to attract 
attention, and in some cases will be likely to escape detection 
unless particular attention be paid to the objective symptoms, 
such, for example, as a slight discoloration of the iris, or some 
cloudiness of the aqueous humor. 

Ophthalmoscopic Symptoms. — These are : (i) a char- 
acteristic "cupping" of the optic nerve disc ; and (2) pulsation 
of the retinal arteries. The glaucomatous, or "pressure" 
excavation, as the cupping of the optic papilla is sometimes 
called, is easily distinguished from the other two forms ; 
namely, from what is known as the congenital or physiological 
excavation, and also from that which characterizes simple 
atrophy of the optic nerve, by not being partial or limited to 
the central portion of the optic disc, as in the former, nor by a 
gradual sloping from its edges, towards the centre, as in the 
latter ; but the cup extends quite up to the edge of the disc, 
from which the lamina cribrosa suddenly retreats, as if pushed 
directly backward by the increased intra-ocular pressure- 
Indeed, so abrupt and precipitous are its edges, that the latter 
may even over-hang the cup, as though the margin were un- 
dermined. The cupping of the papilla is made apparent by 
the course of the retinal vessels as they pass over the edge of 
FIG - IO - the excavation. Instead of 

passing straight over the mar- 
gin of the disc, as in the nor- 
mal eye, (Fig. 10), we find 
that as they descend into the 
excavation they make a more 
or less abrupt curve ; and if 
the edges of the excavation 
are undermined, the veins, as 
they curl over them, appear to 
be so much displaced, that 
when they reappear on the 
optic papilla, N orma L .* optic disc they no longer 




*After Zander. 



CHRONIC NON-INFLAMMATORY GLAUCOMA. 21/ 

seem to be the same vessels. This is especially the case if the 
excavation is deep, the displacement sometimes equalling, or 
even exceeding, the diameter of the vessel. 

Spontaneous pulsation of the retinal veins is a common 
occurrence in healthy eyes ; but spontaneous arterial pulsation 
is known to occur only in cases where there is insufficiency of 
the aortic valves, or where the intra-ocular tension is consid- 
erably increased. The pulsation is generally limited to the 
optic disc, and is of a rapid and somewhat jerky character. 

ETIOLOGY. — Many theories have been advanced to 
account for the glaucomatous process ; of these not more than 
three appear to be of sufficient importance to claim our atten- 
tion. The first attributes the increased eye tension, and excav- 
ation of the optic disc, to hypersecretion of the fluids of the 
eye, the result of some abnormal irritation of the secretory 
nerves, which irritation is regarded as a reflex from the sym- 
pathetic. The second attributes the glaucomatous symptoms, 
primarily, to inflammation of the uveal tract ; the other struc- 
tures of the eye becoming secondarily involved. According to 
this theory, the irido-choroiditis first gives rise to hypersecre- 
tion of the vitreous humor, and this causes an increase of the 
intra-ocular tension, which latter, by its interference with the 
circulation, occasions the glaucomatous symptoms. The 
third and last theory which we shall notice, attributes the 
disease to a want of elasticity in the sclerotica. The fact that 
glaucoma is pre-eminently a disease of advanced life, and 
generally attacks only those whose age exceeds forty or fifty 
years, in whom the sclerotica appears comparatively rigid and 
unyielding, is regarded by the advocates of this theory as 
furnishing conclusive evidence that the disease is due to con- 
gestion in the internal circulation caused by a rigid and un- 
yielding capsule. We have not room to examine these theories 
in detail, but are inclined to regard the inflammatory theory 
as the most tenable, notwithstanding the fact that some cases 

28 



218 PRACTICE OF MEDICINE. 

of glaucoma simplex seem to run their course without any, or 
at least with but very little, appearance of inflammatory 
symptoms. It should be remembered, however, (i), that the 
absence of any external, or of any subjective signs of external 
inflammation, is no proof of its non-existence, the contrary 
having been frequently established by ophthalmoscopic evi- 
dence ; and (2) that, in the vast majority of cases, inflamma- 
tory symptoms of greater or less severity do show themselves 
at some period of the disease. On the other hand, there can be 
but little doubt that rigidity of the sclerotica has more or less 
to do with the origin and progress of glaucoma. For, as Wells 
very appropriately observes, we find that in youthful indivi- 
duals, in whom the sclerotica is more elastic and yielding, an 
increase of the intra-ocular tension, dependent upon some 
inflammation of the uveal tract, may exist for some time 
without exerting any deleterious effect upon the optic nerve or 
retina. 

PROGNOSIS. — Previous to the year 1856, when Von Graefe 
discovered the value of iridectomy in this disease, glaucoma 
was justly regarded as incurable ; for the disease is of such a 
progressive and destructive character, that if left to itself, or 
if treated exclusively by other remedies, it leads, sooner or 
later, to atrophy and permanent blindness. On the other hand, 
so effective has the operation of iridectomy proven in relieving 
intra-ocular tension, and in arresting the progress of the 
disease, that in those cases in which irreparable damage to the 
structures of the eye has not yet taken place, the glaucoma- 
tous symptoms have been greatly benefited, and in most cases 
have entirely disappeared. Much, however, depends upon the 
kind as well as the stage of the disease. Glaucoma fulminans, 
from the rapidity with which it runs its course, is extremely 
dangerous. Secondary glaucoma, especially that which super- 
venes upon hemorrhagic effusions, is equally dangerous, the 
operation either proving inefficient, or else complicating the 



CHRONIC NON-INFLAMMATORY GLAUCOMA. 219 

disease by increasing the hemorrhagic effusion. The prognosis 
in the latter stages of acute glaucoma, as well as in the chronic 
inflammatory form, must be guarded ; since in the first case 
there may already be such a deterioration of the retina and 
cupping of the optic nerve, as to render any improvement from 
the operation temporary and imperfect ; and in the latter, the 
progress of the disease is so insidious, that serious structural 
changes of the retina and optic nerve, and especially atrophy 
of the latter, may occur before treatment is instituted. 

Treatment. — As already indicated, operative measures 
stand at the head of remedial agencies in this affection ; and 
of these iridectomy is incomparably the most efficient. When 
we take into consideration the fact that in the early stages of 
glaucoma, iridectomy is almost a certain cure for it, it is evi- 
dent that to postpone the operation a single day after the 
disease fully declares itself, is to incur a great and unnecessary 
risk. It is true the operation sometimes cures even in the 
later stages, and in nearly all cases it proves palliative, but in 
order to insure the greatest benefit from it, the sooner it is 
performed the better. The operation is similar to that already 
described, {see Iritis), except that the incision is made in the 
sclerotica, near its junction with the cornea, instead of being 
made in the cornea itself, in order that by extending the incis- 
ion quite up to the ciliary border, a larger section of the iris 
may be secured ; for the same reason, also, the opening is 
made as large as the keratome will allow.. In no other way 
can the intra-ocular tension be so effectually and permanently 
relieved. Neither myotomy, or division of the ciliary muscle, 
nor paracentesis, nor the more recent operation of sclerotomy, 
can compare in effectiveness with a large iridectomy. Even a 
smaller iridectomy, such as is made through the cornea for 
artificial pupil, is not likely to be followed by permanent and 
satisfactory results. 

But while there can be no question as to the propriety of 



220 PRACTICE OF MEDICINE. 

operating as soon as possible after the disease has fully 
declared itself, or after the congestive and inflammatory 
symptoms have ceased to intermit and have become remittent, 
the case is different during the purely premonitory stage- 
During this period we may reasonably expect to benefit the 
patient by the careful administration of well-selected constitu- 
tional remedies. This will be obvious when we take into 
consideration the fact that, in the great majority of instances, 
there co-exist various constitutional disturbances, such as 
rheumatism, gout, derangements of the menstrual function, 
hemorrhoids, etc., all of which are amenable to treatment, and 
which exercise more or less influence upon the disease. But 
in order to prove curative they must be administered during 
the period of intermission : if used later than this they must 
possess the quality of reducing intra-ocular tension, otherwise 
they will prove to be of little or no benefit. We have has yet 
discovered no remedy which will surely and permanently 
produce this effect, although there are several medicines that 
are capable of causing the subjective symptom of tension 
within the eye. As before observed, we should be careful not 
to confound this symptom with the objective sense of hard- 
ness ; but as the latter is probably due, at least secondarily, to 
hypersecretion of the ocular fluids, it is not at all unlikely 
that we may yet find remedies which are capable of reducing 
or limiting it, by causing, perhaps, a retrograde metamorphosis 
to take place within the affected tissues. However this may be, 
we should endeavor, with the light we now have, to equalize 
the circulation and remedy constitutional derangements, 
especially during the premonitory period. 

THERAPEUTIC INDICATIONS. 

Arsenicum. — Deep-seated throbbing pain in the eyeball, 
especially at night ; photopsy ; obscuration of sight, amount- 
ing at times to almost complete blindness ; periodic burning 



CHRONIC NON-INFLAMMATORY GLAUCOMA. 221 

pains in and around the eye, worse at night or after midnight. 
Especially indicated in cases where there is an increase of the 
aqueous humor. 

Belladonna. — Obscuration of sight, with dilatation of 
the pupils ; rapidly increasing presbyopia ; hypermetropia ; 
rainbow colors around flames, especially when the red pre- 
dominates ; aching pressure within the eye ; also burning pains 
in and around the eye, especially when accompanied with con- 
gestion to the head and face. The best results are obtained 
by using the remedy tolerably high, say the 200th, never less 
than the 30th. 

Bryonia. — This remedy is indicated when there is sore- 
ness to the touch in the ciliary region, accompanied with sharp 
shooting pains in the eyes, extending to the head and face; 
also when there is a sense of fullness and pressure, as though 
the eyes were being forced out of the sockets ; aggravation of 
the pains by moving the eyes, or by any exertion of them in 
reading or writing, especially at night. 

Cedron. — Severe ciliary neuralgia, especially when the 
pains are distinctly periodical ; dilatation of the pupils, with 
dimness of vision ; eyes injected and sore to the touch. This 
remedy is most useful in relieving ciliary irritation and neural- 
gia, especially when the pains appear to follow the course of 
the supra-orbital nerve. 

Cimicifuga. — This is one of our most reliable remedies 
for ciliary neurosis, especially when there is a sense of enlarge- 
ment of the globes, the eyes feeling as though they would 
be pressed out of the sockets ; also when there are amblyopic 
symptoms, with dilated pupils ; or congestive headache, with 
aching in the eyes and lachrymation. 

Conium. — Dilatation of the pupils, with dimness of 
sight, especially when accompanied with protrusion ; feeling of 
pressure in the eyes, especially when reading, writing, or doing 
any fine work ; also for photophobia and photopsy, particularly 
in scrofulous subjects. 



222 PRACTICE OF MEDICINE. 

Gelseminum. — Amaurotic symptoms, with dilatation of 
the pupils ; disturbances of the power of accomodation; pain 
in the eyes, either with or without lachrymation. Especially 
indicated in choroidal and venous congestions, either with or 
without serous effusion. 

Hamamelis. — This remedy is indicated in all venous 
congestions of the eye associated with hemorrhoids, especially 
if there is much conjunctival vascularity, ciliary neuralgia, 
photophobia and lachrymation. 

Kali tod. — Amaurotic symptoms, with dilatation of the 
pupils; burning in the eyes; lachrymation, and a dull, discolored 
state of the iris. This remedy, which is of undoubted value 
in every form of choroidal congestion and inflammation, has 
appeared to give relief in many cases of incipient glaucoma, 
especially when occurring in syphilitic constitutions. 

Phosphorus. — This remedy has been found useful in glau- 
coma, especially when accompanied with determination of 
blood to the eyes, photopsy, photophobia, cromopsia, or play 
of colors around flames, and lachrymation ; also when atten- 
ded with a sensation of pressure in the eyes, dimness of vision, 
and dull orbital and circum-orbital pains. 

Phytolacca. — Dimness of vision, with hypermetropia or 
rapidly increasing presbyopia ; dull, aching pain in the eye- 
balls, worse from motion, light, or exercise. Especially suited 
to rheumatic and syphilitic cases. 

Rhododendron. — Incipient glaucoma, accompanied with 
violent attacks of pain in the orbit and head, always worse on 
the approach of rough weather, or of a thunder storm, and 
ameliorated when the storm sets in. The pains are of a 
burning, shooting character, and distinctly periodical. The 
remedy is best adapted to rheumatic subjects. 

Spigelia. — Sharp stabbing pains through the eye and cor- 
responding side of the head, worse at night and on motion. 
The remedy is particularly indicated if, along with dimness of 
vision, there is presbyopia, strabismus, or photopsy. 



PRACTICE OF MEDICINE. 223 

Sulphur. — This medicine is generally most useful as an 
intercurrent remedy, especially in scrofulous cases. The 
special indications are ; gradual diminution of the power of 
vision ; illusions of sight, photopsy and photophobia ; sharp, 
sticking or stabbing pains in the eyes, worse on motion and at 
night. 

In addition to the above remedies, the following have also 
been recommended : Arm, Cham., Cocc, Colch., Collin., Col- 
ocynth, Crot. tig., Hepar, Merc, Nuxv., Prunus spin., Val. Zc. 

Diet and Regimen. — The diet should be liberal, nutri- 
tious, and easily digestible, especially for scrofulous constitu- 
tions and elderly patients. Stimulants should be avoided by all 
except those addicted to their use, and then used only in a feeble 
state of the system, the object being in all cases to keep the 
health in the best possible condition. Bright light should 
always be avoided, or the eyes protected by amber or smoke- 
colored glasses. The eyes should enjoy perfect rest during the 
attacks, or when the latter follow each other in quick succes- 
sion ; and in no case should they be used for near objects, or 
when exercise causes pain or provokes an attack. 

ART. XI. — CHOROIDITIS. 

We have already considered anterior, or partial choroiditis, 
under the head of irido-choroiditis ; and one of the most 
important and complicated forms of general choroiditis has 
been described under the head of glaucoma. It remains to 
consider (i) simple serous choroiditis; (2) disseminated or 
exudative choroiditis ; (3) suppurative choroiditis ; and (4) 
sclerotico choroiditis posterior, or posterior staphyloma. 



224 PRACTICE OF MEDICINE. 

l.-SIMPLE SEROUS CHOROIDITIS. 

Symptoms. — This form of choroiditis is chiefly character- 
ized by diffuse cloudiness of the vitreous humor and consequent 
diminution of vision. The disease is frequently complicated, 
sooner or later, with serous iritis, the iris becoming more or less 
discolored, the pupil dilated or adherent to the anterior cap- 
sule, the aqueous humor hazy and more or less turbid from 
particles of floating lymph, and the posterior surface of the 
cornea clouded with similar deposits, {Keratitis punctata). The 
diffuse turbidness of the vitreous is rendered more opaque by 
fixed or floating opacities, of a filiform and membranous 
character, which, according to Graefe, affect the structure of 
the vitreous humor, leading to the destruction of its septa, and 
even to the dissolution of the zonule of Zinn. The relaxation 
and softening thereby produced frequently give rise to dis- 
placement of the lens. In other cases the intra-ocular tension 
increases, the aqueous humor is secreted in greater quantity, 
the vision becomes more and more impaired, and finallysymp- 
toms of glaucoma appear. These complications, however, 
rarely take place in simple serous choroiditis, the opacities of 
the aqueous and vitreous humors generally disappearing 
altogether, or leaving only a slight amount of cloudiness in the 
ciliary region. 

Treatment. — Little more is generally required in the 
way of treatment, than to keep the eyes in a state of perfect rest, 
to protect them against bright lights, cold, dampness, etc., to 
keep the pupil dilated with Atropine, and to hasten the absorp- 
tion of the vitreous opacities by the internal administration of 
Kali iod. In those cases in which the intra-ocular tension is 
increased, the operation of paracentesis may be tried ; but if 
this fails to relieve, and secondary glaucoma sets in, it will 
probably be necessary to perform the operation of iridectomy, 
(which see). Aurum, Bryonia, Colocynth, Gelseminum, 
Ipecacuanha, Phosphorus, Psorinum, and Sulphur, have been 
employed in these cases with favorable results. (See Glaucoma). 



PRACTICE OF MEDICINE. 225 

2.-DISSEMINATED CH0H0IDITIS. 

SYPHILITIC OR EXUDATIVE CHOROIDITIS. 

SYMPTOMS. — The subjective symptoms of this affection 
are often so light during the early stages, that its existence is 
frequently not suspected until after the disease has made con- 
siderable progress. There is generally little or no pain, 
photophobia, lachrymation, or vascular injection ; the iris is 
but slightly implicated ; and the only symptom of which the 
patient is apt to complain, is a peculiar impairment of sight, 
in which the vision is more or less obstructed and distorted by 
dark, fixed, cloud-like opacities appearing before it. These 
scotomata, as they are called, are supposed to be due to the 
dissemination or exudation of matter from the choroid upon 
the under surface of the retina, the pressure of which upon 
the latter impairs its function by injuring or destroying some 
of its elements. The injury to vision is, of course, greatest 
when the exudations are situated in the region of the yellow 
spot, and least when confined to the anterior portion of the 
fundus. The vitreous humor sooner or later becomes diffusely 
clouded, and frequently exhibits fixed or floating opacities, of 
a filimentous or membranous appearance. These vitreous 
opacities sometimes make their appearance previous to that 
of the choroidal exudations before mentioned. The latter, 
which are far the most important, vary in size from a millet 
seed to large circular patches. They occur both in the stroma 
and upon the retinal surface of the choroid. At first they are 
of a dull, yellowish color ; but at a later period the exudative 
masses are absorbed, leaving the corresponding parts of the 
choroid so much thinned as to be more or less transparent, so 
that the subjacent sclera shines through the patches, giving 
them a somewhat pearly, glistening appearance. The patches 
are more or less irregular in shape, and are rendered very con- 
spicuous by proliferation of epithelium pigment cells upon 
29 



2 26 PRACTICE OF MEDICINE. 

their borders, the blackness of which contrasts strongly with 
the whiteness of the more central portions. 

The exudation may commence either at the periphery or 
at the posterior pole of the eye, from which parts it becomes 
gradually disseminated over the fundus. In the latter case, 
the patches sometimes exhibit pale-red areolae round them, 
which are thought by some to indicate a syphilitic origin. 
Notwithstanding, however, this is probably the most common 
form of specific disseminated choroiditis, it is far from being 
the only one, as we find that almost every variety of the 
disease is sometimes due to syphilis. 

DIAGNOSIS. — The only certain diagnostic signs of the 
disease are the ophthalmoscopic symptoms ; but these are so 
peculiar as to render it almost impossible to mistake dissemin- 
ated choroiditis for any other form of the affection, so long as 
the vitreous remains sufficiently transparent to allow the details 
of the fundus to be made out. As to the precise seat of the 
exudations, we may readily satisfy ourselves that it is in the 
choroid, by observing that the retinal vessels can be traced 
directly over the patches, and are not obstructed in their course, 
or rendered the least indistinct by them ; moreover, the retinal 
veins retain their normal calibre and straightness, and the 
retina its usual appearance and transparency. At a later 
period, the retina generally becomes thinned and atrophied by 
the pressure of the exudations ; and not unfrequently the optic 
nerve, also, shows signs of atrophy, the blood-vessels becoming 
more or less indistinct, and in some cases obliterated. 

Etiology. — Disseminated choroiditis is found to be most 
frequently associated with syphilis; but the insidious form 
complicated with serous iritis sometimes occurs in lymphatic, 
scrofulous, and consumptive patients. 

Prognosis. — The prognosis should always be guarded, 
especially if the exudations are extensive, or are seated in the 
region of the yellow spot. The most favorable cases, com- 



DISSEMINATED CHOROIDITIS. 22/ 

parativcly, are those of a distinctly syphilitic origin, in which 
the spots are surrounded by reddish areolae. In these and 
other favorable cases, the exudations are sometimes absorbed, 
leaving but slight traces of their former existence behind them. 
In most instances, however, the choroid, retina and optic nerve 
all suffer to some extent, becoming more or less atrophied and 
disorganized. 

Treatment. — Disseminated choroiditis has been treated 
most satisfactorily, in its early stages, with Merc. cor. and Kali 
iod. These two remedies are not only indicated in all cases 
dependent upon a syphilitic basis, but they are also serviceable 
in every other form of choroidal inflammation, especially when 
complicated with iritis. Nux. v. and Phos. ac. are found to 
be the most useful remedies after the vision becomes impaired 
in consequence of atropic changes in the retina and optic 
nerve. Of the other remedies which have proven curative, or 
which have been found useful in this affection, the following 
are especially worthy of attention : Ars., Bell., Cact, Con., 
Phos., Rut., SiL, Sol. n., Spig. and Sulph. The selection 
should be governed, to a great extent, by the condition of the 
digestive, assimilative, and uterine organs. 

Diet and Regimen. — The diet should be plain, unstim- 
ulating, nutritious, and easily digestible. The patient should 
be careful to abstain from all use of the eyes in reading, 
writing, etc., and to protect them against bright lights by 
wearing colored glasses. Moderate exercise in the open air, 
and whatever tends to invigorate the constitution, will be likely 
to prove beneficial. 

3.-SUPPURATIVE CHOROIDITIS. 

PANOPHTHALMITIS. 

SYMPTOMS. — As the name denotes, this form of choroiditis 
is characterized by the formation of pus in the choroidal 
tissues. It generally assumes from the first the character of a 



228 PRACTICE OF MEDICINE. 

very acute and severe inflammation, in which sooner or later 
the choroid, iris, conjunctiva, and all other vascular tissues of 
the eye participate ; hence it is frequently termed /^-ophthal- 
mitis. The eyelids also become red, hot, and tender, or swollen 
and cedematous, especially the upper lid, which often overlaps 
the lower in large puffy rolls. Both the palpebral and ocular 
conjunctivae are injected and swollen, the chemosis being so 
great as to cover the cornea, or to surround it in the form of a 
tense, livid, circular fold or ring. In these cases the conjunc- 
tiva appears dry, and more or less encrusted with exudative 
matter ; but when the inflammation is milder, the secretion is 
not arrested, but oozes out from between the lids in the form of 
muco-pus. If the chemosis is not too great, and the cornea is 
clear, we generally find the iris bulged forward, discolored, and 
its stroma infiltrated with pus ; and if the pupil is dilated, it 
also is frequently of a yellowish tint, owing to a purulent 
infiltration of the vitreous. Sometimes, however, the pupil is 
contracted, its area occluded with lymph, and its margin adher- 
ent, perhaps, to the anterior capsule. The anterior chamber is 
rendered shallow by the bulging of the iris, the aqueous humor 
is clouded, and not unfrequently we discover below the pupil a 
considerable hypopyon. In other cases the cornea is opaque 
from becoming infiltrated with pus, and either breaks down 
into a mass of purulent matter, or shrinks into a thin, yellow- 
ish, rudimentary membrane. The eye is extremely sensitive 
and painful, and owing to inflammatory swelling of the orbital 
tissues, protrudes more or less from its socket; it is also greatly 
limited in its motions, and even rendered immovable by the 
surrounding swelling. The intra-ocular tension is increased, 
and the globe more or less enlarged. These symptoms are 
generally accompanied by intense pain, mostly of a paroxysmal 
character, which radiates from the eye to the orbit, head, and 
corresponding side of the face. The disease is also attended 
with fever proportionate to the local disorder, which is some- 



SUPPURATIVE CHOROIDITIS. 229 

times accompanied with considerable gastric disturbance. 
Vision is soon lost, but the patient remains troubled by the 
subjective symptoms of photopsia, or flashes of light, and 
chromopsia, or the appearance of colored spectra before the eyes. 
Sooner or later perforation occurs, either through the cornea 
or between the recti-muscles, and then the suffering is greatly 
mitigated. In some cases the pain and other inflammatory 
symptoms are much less severe, while at the same time the 
suppurative process is equally as extensive and disastrous. 
Even the retina undergoes suppurative changes, and also 
becomes more or less detached from the choroid, in consequence 
of serous or hemorrhagic effusions from that membrane. 

ETIOLOGY. — The most frequent causes of suppurative 
choroiditis are traumatic injuries, both accidental and surgical, 
especially those involving the ciliary region. Chemical injuries, 
blows, concussions, and other like causes, may also give rise to 
it ; but it is much more apt to follow penetrating wounds and 
surgical operations, such as are connected with the removal of 
the lens in cataract operations, or the lodgment of bits of metal 
or other irritating substances within the eye ; in short, whatever 
is capable of giving rise to sympathetic ophthalmia, or of 
exciting suppurative inflammation in the cornea or iris, 
is liable to be followed by panophthalmitis, especially 
in cases complicated with typhus, cerebro-spinal menin- 
gitis, puerperal fever, and other low states of the system. 

PROGNOSIS. — This is so unfavorable, that unless the 
disease is seen in its very incipiency, there will be very little 
chance of arresting it before it has destroyed the vision, or 
even before it has led to disorganization and collapse of the 
globe. In most cases it runs a very rapid course, and termin- 
ates in perforation and atrophy of the eyeball. The worst 
results are generally met with in metastatic cases, such as occur 
in cerebro-spinal meningitis or pyemia, since, both eyes being 
involved, if the patient does not die of the primary disease, 



230 PRACTICE OF MEDICINE. 

which is usually the case, he will most probably be left totally 
blind. The suppurative process is, however, sometimes, though 
very rarely, limited to a very small portion of the globe, and 
if under these circumstances the pus escapes, either by perfor- 
ation or otherwise, a certain and sometimes very useful degree 
of vision may be preserved ; but in the vast majority of cases 
perforation does not take place until the eye is irreparably 
injured and the sight destroyed: The globe now generally 
becomes more or less atrophied, shrivelling up into a small 
nodular stump, not larger perhaps than a pea, or it may retain 
for a longer or shorter period a certain degree of fullness and 
sensibility, subject to repeated attacks of inflammatory action, 
especially if the opening becomes temporarily closed. In these 
cases, if there is much ciliary irritation, and especially if it is 
kept up by the presence of a foreign body within the eye, the 
other eye may become sympathetically involved, as stated 
under the head of sympathetic ophthalmia. At last, however, 
all inflammatory action subsides, and then the suppurative 
process ceases, the perforation becomes permanently closed, 
and the globe dwindles away until it becomes completely 
atrophied. 

Treatment. — Whenever suppurative choroiditis is threat- 
ened, its occurrence should if possible be prevented, by 
directing the treatment against any exciting cause that may 
be discovered. Thus, if a bit of metal or other foreign body 
has entered the eye, it should be carefully and speedily remov- 
ed, especially if it has penetrated the ciliary body. If it 
has injured the lens, or if the latter is swollen and cataractous, 
the lens should be extracted by the flap operation, removing at 
the same time a portion of the iris. If there is a large hypop- 
yon, and especially if it is complicated with corneal abscess, 
paracentesis or iridectomy should be performed. If the eye is 
badly bruised or lacerated, and the vision hopelessly destroyed, 
and especially if a foreign body also remains in the eye, the 



SUPPURATIVE CHOROIDITIS. 23 1 

latter should be removed at once, in order to prevent the occur- 
rence of both suppurative choroiditis and sympathetic ophthal- 
mia, for it is not always safe to enucleate the eye after the 
suppurative process begins, After suppuration once sets in, 
there will of course be little if any chance of saving the eye, 
but the suffering may be greatly relieved, and for this purpose 
the remedies best calculated to allay ciliary irritation and sub- 
due inflammation will be the most efficacious. If the inflam- 
mation is very severe, and especially if the case is seen early, 
ice-water compresses will be indicated ; but if the latter are 
not well borne, or if suppuration has begun, and there is intense 
ciliary irritation and neuralgia, warm applications will be the 
most soothing as well as the most beneficial. If the intra- 
ocular tension is increased and the pain is very severe, par- 
acentesis, repeated several times if necessary, or an iridectomy, 
will give great relief; but if the sclerotica is distended with 
purulent matter, or we have reason to believe that there is any 
considerable accumulation of pus in the interior of the eye, it 
will be advisable to open the abscess at once by making a deep 
and free incision into it. Finally, if the suppurative process is 
so protracted as to undermine the health, and especially if its 
continuance threatens the life of the patient, the eye should 
be enucleated without hesitation, notwithstanding the danger 
thereby incurred of the disease extending itself to the meninges 
of the brain. 

THERAPEUTIC INDICATIONS. 

Aconite is a useful remedy whenever there is high fever, 
especially in the first stages of the disease, or when the lids 
are red, hot, dry and swollen. 

Apis is recommended when the lids are cedematous and 
the conjunctiva chemosed, with stinging pains through the 
globe. 

Arnica is indicated during the first stage when the disease 



232 PRACTICE OF MEDICINE. 

is of traumatic origin, if the lids are swollen and echymosed, 
and the globe protruded, tense and painful. 

Arsenicum is sometimes useful in cases attended with rest- 
lessness, thirst, cedematous swelling of the lids and conjunctiva, 
and deep-seated throbbing and burning pains, especially if 
there is much prostration of the system. 

Belladonna is indicated when there is intense ciliary neu- 
ralgia, with burning dryness in the eyes, pain in the orbits, and 
a severe aching pressure within the globe. 

Hepar sulph. is indicated after suppuration has commen- 
ced. The eye is protruded and externally tender to the touch ; 
the lids are highly inflamed and swollen, especially the upper ; 
and the pains are deep, throbbing, and ameliorated by warmth. 

Mercurius is useful in the first stage, when there is much 
burning in the eyes, with ciliary injection and more or less red- 
ness and swelling of the lids. 

Rhus tox. is said to be useful in every stage of the disease, 
especially the first. The indications are : cedematous swelling 
of the lids ; chemosis of the ocular conjunctiva ; severe orbital 
and circum-orbital pains, aggravated at night and during rainy 
and rough weather. 

Bryonia, Phytolacca, Silicea, Sulphur, and a few other 
remedies have been recommended, and may occasionally be 
found useful, not so much by virtue of any direct influence 
they may have upon the diseased organ, as by contributing to 
the general physical and mental well-being of the patient. 

Diet and Regimen. — As in other suppurative diseases, 
the strength will need to be sustained by a free allowance of 
the most nourishing diet ; and in some cases it may be advis- 
able to administer stimulants, especially if the patient is very 
much prostrated, or is old and feeble. 



PRACTICE OF MEDICINE. 233 

i-SCLERO-CHOROIDITIS POSTERIOR. 

SCLERECTASIA POSTERIOR — STAPHYLOMA POSTICUM. 

SYMPTOMS. — Sclero-choroiditis posterior is chiefly char- 
acterized by an intra-ocular inflammation involving the fundus 
of the globe, and accompanied with a greater or less degree of 
myopia. The inflammation and accompanying myopia may 
exist either with or without a posterior staphyloma of the 
sclera ; and in like manner the bulging of the sclera may occur 
without giving rise to any appearance of inflammation in the 
fundus ; hence, although these conditions are often associated 
together, there is no necessary connection between them, and 
therefore the old notion that staphyloma posticum results 
from inflammation is, as a rule, erroneous. Nevertheless, when 
the staphylomatous process advances rapidly, and in nearly 
every case in which there is a considerable degree of myopia, 
an inflammatory condition of the fundus sooner or later super- 
venes, and gives rise to sclero-choroiditis. 

The characteristic ophthalmoscopic symptom of staphy- 
loma posticum is a bright, yellowish or bluish-white line or 
crescent at the edge of the optic disc. It may be limited to 
one side, generally the outer, or it may extend quite around the 
disc, the broadest part being in the direction of the yellow spot. 
Although its general form is that of a single or double cres- 
cent, its shape may be quite irregular, assuming in some cases a 
more or less pointed, in others a zigzag, and in others, still, 
a wavy outline, which may be sharply defined, or may 
gradually fade away into the neighboring tissues. The crescent 
is often spotted or marbled over with small patches of dark 
pigment, especially on its edges, where the pigment cells of 
the choroid are not yet entirely destroyed by the advancing 
atrophy. It is owing to this thinning of the stroma of the 
choroid, that the sclera, shining through the former, gives to the 
crescent its usual glistening-white appearance. 



234 PRACTICE OF MEDICINE. 

Amblyopic symptoms, due chiefly to disturbances in the 
intra-ocular tension, frequently manifest themselves. As a 
general rule, the more rapid the development of the staphy- 
loma, the greater will be the disturbance of vision. This 
arises partly from the hyperaemic condition of the venous sys- 
tem of the eye, and partly from irritability of the retina. The 
latter is generally most pronounced when, along with the 
amblyopia and disturbance of vision, the patient is troubled 
with photopsies, such as flashes of light, dazzling points, colored 
corruscations, etc., or when exposure to the light causes a sense 
of pain and tension in the eye. 

As in other forms of choroiditis, the inflammation fre- 
quently gives rise to cloudiness or opacity of the vitreous 
humor, especially in its posterior part, which is sometimes 
detached from the retina by a thin, serous-like transudation. 
These opacities, which are both movable and fixed, are espec- 
ially annoying to the patient, whose short-sightedness renders 
them unusually distinct. The most serious form of vitreous 
opacity is that which generally precedes detachment of the 
retina, and is supposed to be due to a separation of the vitreous. 
The following is Iwanoff 's explanation : — The vitreous humor 
does not expand in proportion as the proterior chamber of the 
eye is increased in volume by the staphyloma, but the vitreous 
recedes from the retina, and the space thus formed between 
them is filled with a serous exudation, which detaches the 
vitreous more and more from the limiting membrane, and not 
unfrequently separates the latter from the subjacent retina. 

Secondary glaucoma, in the form of serous irido- 
choroiditis, frequently supervenes in the course of sclero- 
choroiditis posterior, accompanied with periodic cloudiness of 
the aqueous humor, effusions into the vitreous, and glaucom- 
atous excavation of the optic nerve.. The latter varies greatly 
in different cases, being in some instances extremely steep and 
abrupt ; in others it is quite shallow, or confined, apparently, 



SCLERO-CHOROIDITIS POSTERIOR. 235 

only to the margin of the disc ; and in other cases the disc or its 
margin is not only cupped, but the latter is surrounded by a 
second excavation, which is situated in the sclerotic near the 
edge of the disc. In these cases vision is relatively far less 
affected than in similar conditions in primary glaucoma, in 
consequence, no doubt, of the relief afforded to the intra-ocular 
tension by the staphylomatous enlargement. Nevertheless, 
iridectomy should be performed as early as possible in all cases 
where the contraction of the field does not already encroach 
closely on the centre, in which latter class of cases, according 
to Graefe, the operation sometimes proves injurious. 

ETIOLOGY. — Staphyloma posticum is generally hereditary. 
Although denied by some, it has been satisfactorily shown by 
Jaeger and others, that it is by far the most common in the 
children of myopic parents. Its subsequent development is no 
doubt chiefly due to a hyperaemic condition of the fundus, 
caused by the severe and long continued straining of the accom- 
modation of the eyes for near objects. The main reason that 
the elongation of the eye takes place at the posterior pole, is 
because the latter receives no support from either the capsule 
or the muscles of the globe ; but the enlargement is also fav- 
ored by the conjoint effects of the relaxation caused by the 
intra-ocular congestion, and the extension resulting from the 
increased pressure of the fluids. This extension gives rise to 
atrophy of the choroid, which is still farther increased by the 
consecutive inflammation that sooner or later supervenes. 

PROGNOSIS. — The prognosis should always be guarded, 
since, although no further development of the ectasia may take 
place for many years, yet it is liable to occur at any time, and 
to progress with great rapidity. This is especially to be feared 
if there is already a co-existing choroiditis, particularly if the 
visual field is much clouded by it, or if there exist diffuse 
opacities of the vitreous threatening the retina. 

Treatment. — The first and most important point to be 



236 PRACTICE OF MEDICINE. 

observed in treatment is, to see that the patient gives his eyes 
sufficient rest, and that when in use he does nothing that will 
be likely to over tax their accommodative power. He should 
therefore be specially warned against using his eyes for any 
considerable length of time on near and fine objects, even with 
suitable glasses, as these require extreme convergence of the 
visual axes, and thus overtax the power of accommodation ; it 
also tends to increase the hyperaemic condition of the fundus, 
and to enlarge the posterior staphyloma, by causing undue 
pressure of the external muscles. Care should also be taken 
not to expose the eyes to the direct glare of the light, nor to 
continue using them after a sense of fatigue sets in, especially 
for near objects ; neither should they be used in a stooping 
posture, as this favors congestion. If the light is too dazzling, 
and especially if it causes headache and ciliary neuralgia, it 
should be tempered by wearing blue or smoke-colored glasses, 
which always give marked relief. If the eye is very irritable, 
and especially if there is a hyperaemic state of the optic disc, 
all use of the organ for such purposes as reading, writing, 
sewing, etc., should be abandoned, and the eye should be 
allowed perfect rest until all the symptoms of irritation and con- 
jestion have subsided, and even for a considerable period after- 
wards. In those cases in which the conjunctiva is more or less 
injected, benefit will generally be derived from the employment 
of a weak collyrium, consisting of a grain of the sulphate of 
zinc or copper, two or three grains of the acetate of zinc, or 
eight or ten grains of borax, each, to the ounce of distilled 
water. 

THERAPEUTIC INDICATIONS. 

Aconite is generally useful in all cases in which there is 
much heat and congestion of the external tunics. 

Belladonna is indicated whenever there is much ciliary 
irritation and neuralgia, especially if there is a hyperaemic 
condition of the optic disc and retina. 



SCLERO-CHOROIDITIS POSTERIOR. 237 

Congestive headache with flushed face, sensitiveness to 
light, and photopsia, is an additional indication. 

Cactus is also a good remedy in these cases, especially if 
there is a congested state of the optic nerve and fundus. 

Cimicifuga is an excellent remedy in most cases of sclero- 
choroiditis with marked internal and external hpyeraemia, 
especially if the eye is sore to the touch, or if there is much 
ciliary neuralgia and irritation. 

Crocus is said to be useful in cases where the pain extends 
from the eye to the top of the head, or from the left eye to the 
right. 

Merc. cor. — This is one of our most reliable remedies in all 
cases where the choroid exhibits marked inflammatory changes, 
and its use in such cases should not be hastily abandoned. 

Phosphorus. — Hyperaemia of the retina with congestion to 
the head, indicated by severe headache, flashes of light, colored 
rings betore the eyes, etc. 

Spigelia. — Severe pain in and around the eyes, especially 
on moving them ; great ciliary nervous irritation and conges- 
tion. 

Zinc. Phos. — Congestion of the fundus, with fiery balls 
and other luminous spectra before the eyes. 

The following additional remedies have also been recom- 
mended : — Atropine, (locally), Gels., Glon., Lyco., Kali iod., 
Nux v. Physostig., Sulph. and Zinc. 

ART. XII. — HYALITIS. 

Inflammation of the vitreous humor is usually associated 
with some other disease of the fundus, such as choroiditis, 
retinitis, etc., but it may also occur idiopathically ; at least 
such is the opinion of most ophthalmologists, although Pagen- 
stecher, who made numerous experiments on the eyes of rabbits, 
came to the conclusion that the disease never occurs as a prim- 
ary affection, but always depends on changes in the neigh- 



238 PRACTICE OF MEDICINE. 

boring structures. Indeed, Galezowski goes so far as to assert 
that the vitreous humor never can become inflamed, since it 
has no organized structure, but that the inflammation is always 
confined to the hyaloid membrane. This, however, is now 
known not to be the case, it having been clearly proven by 
Virchow, Weber and others, that inflammatory changes fre- 
quently occur in the vitreous, and may assume either the 
simple or the suppurative form. 

l.-SIMPLE HYALITIS. 

Simple hyalitis is sometimes, though very rarely, idiopa- 
thic. It is generally secondary to inflammation of the ciliary 
body, choroid or retina, and consequently the symptoms are 
almost always combined with those of an accompanying 
cyclitis, choroiditis or retinitis. 

SYMPTOMS. — The disease is chiefly characterized by diffuse 
opacities within the vitreous. If the inflammatory process is 
much advanced, connective-tissue opacities, of various forms 
and sizes, may sometimes be discerned even by the naked eye, 
glistening indistinctly in the midst of the diffuse cloudiness ; 
but at the commencement the opacities are generally too thin 
and indistinct to be recognized, except by the aid of the oph- 
thalmoscope. Viewed through this instrument, the vitreous 
appears at first more or less clouded, and the optic nerve and 
retinal vessels have an indistinct or blurred appearance, as 
though seen through a mist; the observer may also discover, 
here and there, thicker opacities in the form of dark specks, 
delicate filaments, etc. As the inflammation increases, the 
vitreous humor becomes less and less transparent and the 
cloudiness more evenly diffused, so that the details of the 
fundus are rendered either very indistinct, or become entirely 
invisible. In addition to the fixed and floating opacites above- 
mentioned, neoplastic formations of connective tissue appear 



SIMPLE HYALITIS. 239 

in various portions of the vitreous, having a filamentous or 
membraneous character, which, variously inter-twined and cross- 
ing each other in every direction, divide it into irregular 
sections which sometimes have the form of separate compart- 
ments. These appearances are generally most marked in the 
vicinity of the ciliary body, and at the posterior pole of the 
lens, where the opacity is sometimes so great as to be termed 
posterior polar cataract. In some cases vessels are seen in the 
vitreous, which divide and sub-divide in the most varied 
manner. Sometimes synchesis of the vitreous occurs, that is, 
it becomes partly or completely fluid. This generally occurs 
in proportion to the development of the connective-tissue 
formation. In this state the movable opacities sometimes 
disappear from the visual field by sinking to the bottom of the 
fundus, but re-appear whenever the eye is subjected to any 
rapid movement. Even when the vitreous is not fluid, the 
denser opacities are very movable, floating about more or 
less freely on every quick motion of the eye and head. 
In some cases where fluidity of the vitreous occurs, owing 
to the presence of crystals of cholesterine in the fluid, 
the floating opacities and crystals present the appearance of 
bright, glittering, star-like bodies, the movement of which 
seems to the patient like a shower of stars. In other cases, 
where the proportion of connective tissue in the vitreous 
becomes very large, the latter detaches itself from the 
limiting membrane and shrivels up, until in some instances 

it occupies less than one-fifth of its natural space. In 
these cases, also, the retina is often extensively detached, 
either alone or along with the vitreous, the separation 
finally extending from the ora serrata to the entrance of 
the optic nerve. These changes, according to IwanofT, most 
frequently occur when a foreign body, such as a depressed 
cataractous lens, becomes encapsuled ; they also occur in irido- 
choroiditis, from a gradual shrinkage of the connective-tissue 
products developed in the vitreous as a consequence of inflam- 
matory proliferation. 



24O PRACTICE OF MEDICINE. 

2.-SUPPURATIVE HYALITIS. 

Suppurative hyalitis generally occurs in connection with 
suppurative iritis, cyclitis, or irido-choroiditis. It generally 
supervenes upon injuries of the eye, cataract operations, etc., 
and frequently leads to panophthalmitis and destruction or 
atrophy of the globe. 

Symptoms. — Suppuration may commence in any por- 
tion of the vitreous, and may either remain confined to the 
part in which it originates, or it may spread throughout the 
whole # of the vitreous humor. In some cases the purulent 
matter appears just behind the lens, {posterior hypopyon), and 
is due to pus which has burst through the retina from the 
ciliary body. In this case the other portions of the vitreous 
are frequently normal. Generally, however, the entire vitreous 
becomes involved in the suppurative process, except in the 
case of foreign bodies, which frequently give rise to circum- 
scribed abscesses. 

Etiology. — It is generally conceded that hyalitis usually 
depends oh inflammation of the neighboring structures. In 
our study of cyclitis, irido chorioditis, glaucoma, etc., we have 
seen how uniformly-cloudiness of the vitreous appears amongst 
the symptoms; but it is especially in the more acute and 
suppurative forms of those diseases that it is an invariable 
attendant. It may also be excited by the presence of foreign 
bodies, by wounds of the vitreous humor, by loss of vitreous 
after operations for cataract, by extravasations of blood, etc. 

Prognosis. — Diffuse opacities of the vitreous, when 
dependent on inflammation of the investing vascular structures, 
generally soon disappear in cases where the latter take a fav- 
orable turn and undergo resolution ; but the contrary occurs if 
the inflammation is frequently repeated, or if the neighboring 
tissues are much altered. In short, the prognosis depends 
chiefly upon the cause of the inflammation, and the extent to 
which the surrounding tissues are implicated. 



SEROUS RETINITIS. 24I 

Treatment. — As the removal of the cause constitutes 
the first and most important point in treatment, it is evident 
that whenever the existence of hyalitis depends upon irido- 
cyclitis, irido-chorioditis, or any other disease of the fundus, 
the treatment will require to be directed to the removal of the 
primary affection. (See cyclitis, choroiditis, glaucoma, retinitis, 
etc.) If the inflammation is due to the presence of a foreign 
body in the vitreous, and its location can be determined, either 
with the ophthalmoscope or otherwise, it should be immed- 
iately cut down upon, and removed with a Daviel's spoon, 
(PL I. Fig. 31), the canular forceps, (Fig. 3), or any other con- 
venient instrument. If this is found to be impracticable, then 
the best course is to enucleate the eye at once, and thus save 
the other eye from being destroyed by sympathetic ophthalmia, 
(which see). Fixed opacities remaining after severe inflamma- 
tion of the vitreous, have sometimes been torn or cut through 
with a sickle-shaped needle, (Fig. 8), introduced through the 
sclera, and the vision thereby considerably improved. What 
effect, if any, the long-continued administration of such, 
remedies as Baryta, Causticum, Magnesium, Phosphorus, Sepia, 
Silicea, etc., may have upon them has not yet been satisfactor- 
ily determined. 

ART. XIII. — RETINITIS. 

We are now to consider a class of diseases of the highest 
importance, which previous to the invention of the ophthalmo- 
scope were very imperfectly understood — so much so, in fact, 
as to be confounded with an affection of a totally different 
nature, namely, hyperesthesia of the retina. The latter is 
characterized by intense photophobia, lachrymation, ciliary 
injection and neuralgia, while retinitis, as we shall see, is 
distinguished by no such symptoms. 
31 



242 PRACTICE OF MEDICINE. 

1 -SEROUS RETINITIS. 

(EDEMA OF THE RETINA. 

SYMPTOMS. — Serous retinitis, or oedema of the retina, is 
chiefly characterized by a delicate greyish opacity of the fun- 
dus of the eye, which shows itself in the form of a bluish-grey 
veil or mist spread over the surface of the retina, and which 
hides to a greater or less extent the choroidal vessels. The 
opacity, which is due to a serous infiltration of the connective 
tissue of the retina, may be either general or partial, that is, it 
may affect the whole or only parts of the fundus. In the latter 
case, the ©edematous cloudiness is most marked in the region 
of the optic nerve entrance, but becomes fainter and fainter as 
it approaches the macula lutea, or yellow spot, in consequence 
of the diminished thickness and greater transparency of that 
portion of the retina. As the oedema increases, the details of 
the choroid and optic disc are rendered less and less distinct, 
until, in severe cases, the fundus presents nearly a uniform 
reddish-grey or bluish-grey appearance. In these cases the 
optic disc appears somewhat swollen and indistinct, but the 
opacity is so diffuse and veil-like as to produce but little alter- 
ation in the appearance of the arteries ; the retinal veins, on 
the contrary, are dilated and more or less twisted in their 
course, those in the vicinity of the optic nerve describing com- 
paratively large curves, while the smaller branches are decidedly 
tortuous. The oedematous character of the affection can 
generally be made out by carefully observing the varying 
depths of the vessels in different parts of their course ; as in 
those places where they are the most superficial, they have a 
distinctness and clearness of outline which is lost or obscured 
in parts where they dip more deeply into the effusion. Small 
hemorrhagic extravasations are occasionally to be seen in the 
vicinity of the retinal veins, but they are not often met with in 
this form of retinitis. 



SEROUS RETINITIS. 243 

Externally, the eye appears nearly or quite normal. The 
pupil is sometimes slightly dilated and sluggish, but this is 
seldom very noticeable ; and as there are no symptoms of 
irritability present, such as photophobia, lachrymation and 
ciliary neuralgia, the disease in its first stage is apt to attract 
but little attention. Soon, however, the visual field becomes 
more or less darkened and contracted, and it is this which 
generally leads the patient to apply for treatment. His com- 
plaint is that all objects appear as if enveloped in a mist or 
fog, or as if he was looking through a veil. If the disease is 
partial, or if the opacity is limited to only a small portion of 
the fundus, the corresponding part of the visual field will 
alone be impaired. As the affection progresses, however, both 
peripheral and central vision deteriorate, the sight grows dim- 
mer and dimmer, and if the disease is not arrested the retina 
finally becomes atrophied, and vision is permanently destroyed. 

ETIOLOGY. — Serous retinitis is chiefly due to a hyperaemie 
state of the optic nerve and retina, superinduced by long ex- 
posure of the eye to bright lights, by mechanical violence, and, 
in many cases, by certain constitutional affections, such as 
syphilis, albuminuria, etc. As the causes are similar to those 
of the exudative variety, the etiology will be given more at 
length in the next section. 

PROGNOSIS. — This should be particularly guarded, for the 
reason that the affection is liable to become more or less 
chronic, in which case vision may be lost through atrophy or 
detachment of the retina, or it may take on the exudative 
form, and lead perhaps to disease of the choroid and vitreous. 

Treatment. — The patient should be strictly enjoined 
not to exercise his eyes in reading, writing, etc. He should 
also be careful to protect them from the irritating effects of 
bright light by wearing blue or smoke-colored glasses. 

The internal remedies which have proven most beneficial 
in this form of retinitis are : — Apis, Ars., Bell., Bry., Cact, 



244 



PRACTICE OF MLDICINE. 



Digit., Gels., Merc, Phos., and Puis., the latter, more especially 
when dependent on menstrual irregularities. The following have 
also been recommended in complicated cases, or as intercurrent 
remedies : Aeon., Cimicif., Collin., Con., Croc, Hepar., Nux v., 
Kali iod., Lach., Sulph., and Zinc. For special indictions see 
previous sections. 

As illustrative of the character and treatment of a some- 
what complicated traumatic form of this affection, we subjoin 
an interesting and instructive case from the N. Y. Ophthalmic 
Hospital Rec, 1876, kindly furnished us by F. H. Boynton, 
M. D., Asst. Surg, to the Institution. 

Chas. Birch, aet. 54, Leominster, Mass. Three weeks before ap- 
plication for treatment, (March 4th, 1876), while bending suddenly 
forward, the eye came in contact with the post of a rocking chair ; 
the blow was received in the inner angle of the right eye ; lids soon 
became ecchymosed, slight discoloration still remaining. V=Per- 
ception of light. Field of vision of right eye according to diagram : 

Fig. 11. 
■P 



NO VISION. 




PERCEPTION OF 
OBJECTS. 



Ophthalmoscope shows in right eye diffuse haziness of vitreous, 
serous inflammation of choroid and retina, with effusion under and 
detachment of latter, as represented by diagram. Optic nerve of left 
eye very hyperaemic, V. only -gfo, owing to macula, remnant of 
small pox. 

May 5th. Has consented to come into the hospital for treatment. 



SEROUS RETINITIS. 



24S 



He has been carefully examined by Drs. Allen, Wanstall and myself, 
but no indicative symptoms could be found. On account of the success 
of Gelsemium in several cases of serous choroiditis (non-traumatic) 
in the hands of Dr. Norton, Gels. 30th was prescribed, dose every 
three hours. Patient was put to bed, both eyes being carefully padded 
with lint, and compress bandage applied ; bandage to be reapplied 
three times in twenty-four-hours. Sol- Atropine instilled to insure com- 
plete rest to the accommodation. Low diet. 

14th. Since last date has been constantly in bed. Optic nerve 
very slightly hyperaemic ; few opacities in vitreous ; detachment as 
per diagram and sharply defined. 

Fig. 12. 



NO VISION. 



^ I X 



THIS PART OF FIELD 
CLEAR. 



- 20 
"200* 



Vessels of normal size. Rv.= -££$ ; Lv: 

Heretofore both eyes have been constantly bandaged; now, 
yielding to supplication of patient, allow left eye to be free. 

25th. Field the same ; vitreous becomes quite hazy after moving 
the eye; vision not quite as good ; condition has slightly retrograded 
since allowing one eye free. Now bandage both eyes and confine in 
bed, except one-half hour each day for exercise. Gelsem. 30th. 

April 5th. Ophthalmoscope shows slight opacities in vitreous. 
Field of vision perfect. 

Rv. (floating). V.= jft; with + 36, ^ nearly. 

On the former site of detachment is an exudative choroiditis, 
quite circumscribed (see Fig. 13). Macula lutea, cloudy; nerve, slightly 
hyperaemic. 



246 PRACTICE OF MEDICINE. 

Fig. 13. 




THE ABOVE CUT REPRESENTS THE PATCH OF EXUDATION REMAINING 

8th. Continued and remarkable improvement, very slight hazi- 
ness of fundus ; no flocculi ; nerve still slightly hypersemic. 
V=|-§- without glasses. During the last few days of treatment, I 
experienced much difficulty in retaining the patient in the hospital. 
On the evening of the 8th he surreptitiously took his departure. 

May 19th. I am in receipt of a letter from the gentleman, dated 
May 17th, saying that since he left the hospital, there has been grad- 
ual improvement. For the first three weeks he kept the bed most of 
of the time ; since which time he has been working at his trade 
(joiner) ; experiences some difficulty in doing fine work. 

In recording this most satisfactory result, I experience much em- 
barrassment in deciding how much, if any, credit to give Gelsemium 
as an agent in attaining the desired end ; undoubtedly the recent in- 
vasion, bandaging and complete rest, were active factors. I would 
suggest its use in serous inflammations of the iris, choroid, and retina, 
in those cases not requiring other interference, and its effects noted, 
that there may be no doubt as to its efficacy. 

Note by the Author. — This is a very interesting case, and the 
comments upon it by Dr. Boynton are judicious. That Gelseminum 
exerted a favorable influence cannot, we think, admit of question ; 
at the same time there is no doubt that the immediate instillation of 
Atropine, by diminishing intra-ocular tension, though attended by 



EXUDATIVE RETINITIS. 247 

some risk, contributed powerfully to promote absorption ; and also, 
that the bandaging, rest, and recent invasion, had, as Dr. B. surmises, 
much to do with the speedy recovery of the patient. On the whole, 
we regard this as being in some respects a model case, the treat- 
ment reflecting great credit upon the surgeons of the N. Y. Ophthal- 
mic Hospital. 



2.-EXUDATIVE OR PARENCHYMATOUS RETINITIS. 

SYMPTOMS. — This form of retinitis is characterized by 
inflammatory changes in the parenchyma of the retina, whereby 
the membrane undergoes cell proliferation, hypertrophy, fatty 
or colloid degeneration, and sclerosis. The optic disc is gen- 
erally of a greyish-red or pink color, and its boundaries are so 
indistinct that in many cases its position can only be recog- 
nized by the course of the central vessels, as they emerge from 
the hollow in which they are imbedded in the centre of the 
disc. In these cases the retina loses to a great extent its 
transparency, and becomes dull and dirty looking, with perhaps 
some appearance of striae, or of dark and light spots, which 
give it more or less of a marbled appearance. As a general 
rule, however, it presents a somewhat uniform, but very fine 
granular appearance, in which the natural tint of the subjacent 
choroid is entirely hidden, and the vessels more or less deeply 
veiled. Extravasations of blood, in the form of points or 
small spots, frequently occur, either lying superficially on the 
veins, or situated more deeply, in which case they have a some- 
what indistinct or blurred appearance. When the hemorrhagic 
extravasations are large or very numerous, they constitute a 
distinct form of the disease known as Retinitis apoplectica, 
(which see). 

The pathological changes above sketched vary considera- 
bly in different cases, according to their nature, seat and 
extent. Thus, if the exudation is seated in the more external 
or choroidal layers of the retina, the vessels will not present 



248 PRACTICE OF MEDICINE. 

the indistinct and interrupted appearance that they will when 
it occupies the inner layers, since in the latter case they are 
necessarily more or less hidden by the exudation. We also 
find that, when thus situated, the exudations generally present 
the appearance of light cream-colored or greyish-white non- 
striated spots or patches, over which the retinal vessels are 
seen to pass without interruption. In these cases the in- 
flammatory process frequently originates in the choroid 
instead of in the retina, to which it subsequently extends 
by cell proliferation, giving rise to fatty or colloid degen- 
eration of the external layer, with sclerosis of the external 
limiting membrane. When, on the other hand, the exuda- 
tions are seated in the inner portion of the retina, they 
are generally somewhat striated, and the vessels instead of 
passing straight over them are more or less interrupted, or 
concealed from view. At first the inflammatory changes con- 
sist, chiefly, of hypertrophy of the stroma and connective 
tissue fibres, the latter of which may increase so rapidly as to 
compress, and thereby cause more or less atrophy of the nerve 
fibres. At the same time, the optic nerve fibres and ganglion 
cells increase by proliferation, giving rise to sclerosis, and after- 
wards, perhaps, undergoing fatty degeneration. The internal 
limiting membrane also becomes hypertrophied and uneven, 
occasionally exhibiting upon its inner surface minute eleva- 
tions, caused by under-lying points of exudation. This variety 
of retinitis frequently originates in inflammation of the ciliary 
body and choroid, and is then associated with irido-cyclitis or 
irido-choroiditis. 

Uncomplicated cases are attended with little or no irrita- 
tion, the chief subjective symptoms being a greater or less 
obscuration of the visual field, corresponding to the points of 
exudation. If these occupy the centre of the field, the injury 
to vision will, of course, be much greater than when the centre 
is clear, especially for small or near objects; the obscurity 



EXUDATIVE RETINITIS. 249 

diminishing in proportion as the spots are removed from the 
centre*. Where the exudative form is combined with the 
diffuse, or where the entire retina becomes affected, the 
obscurity is often general, and vision is sometimes reduced to 
a mere perception of light. As a general rule, however, the 
periphery of the retina escapes, and then, if the vitreous also 
remains clear, the patient may be able to so adjust the optic 
axis as to obtain a fair degree of eccentric vision. Moreover, 
the exudations and hemorrhagic effusions may be absorbed, 
the intra-ocular congestion be relieved, the oedema subside, 
and then, if the choroid, retina and optic nerve are not too 
much injured, the vision may decidedly and permanently 
improve. (See Dr. Boynton's case, page 267). But such 
favorable results do not always occur, especially in com- 
plicated cases. Months and even years may elapse before 
the disease makes any considerable progress, and then 
new points of exudation may suddenly appear, accompanied 
perhaps by marked symptoms of inflammation ; or the 
accompanying irido-cyclitis, choroiditis, etc., may subside only 
to burst out again with increased violence; and this may occur 
again and again, each fresh attack or exacerbation developing 
new points of exudation, until finally the inflammation has 
run its course. In these cases the integrity of the retina is 
never entirely restored. The portions of membrane corres- 
ponding to the points of exudation are frequently transformed 
into connective tissue, and although the process of degenera- 
tion by which the transformation is effected is generally very 
slow, it continues until the affected portion of the retina loses 
all sensibility to light, in consequence, probably, of atrophy of 
the nerve elements. In other cases the entire retina as well as 
the choroid and optic nerve undergo atropic changes, and 
vision is hopelessly lost. 

*Micropsia, in which all objects appear smaller to the patient than they really are, 
is sometimes observed in these cases. If, for example, the patient is told to draw a 
certain figure, such as a circle, he will invariably draw it too small. 

32 



2$0 PRACTICE OP MEDICINE. 

ETIOLOGY. — The causes of exudative retinitis are prob- 
ably the same as those which give rise to the diffuse form ; 
indeed, the latter is generally developed along with the former. 
In most cases it is due to some constitutional affection, such as 
syphilis, diabetes, albuminuria, etc. It may also be caused by 
some other disease of the eye, such as irido-cyclitis or chor- 
oiditis ; or it may depend upon disturbances in the circulation, 
such as occur in uterine or heart affections. Among other 
probable causes, we may also mention, long exposure of the 
eyes to intense light, tuberculosis, retinal hemorrhages, cere- 
bral diseases, and even sympathetic influences. 

PROGNOSIS. — This we have already sufficiently indicated. 
During the progress of the disease, so long as the region of 
the macula lutea remains clear, the sight may be sufficiently 
good for the patient to recognize very small objects, and even 
to read the finest print. At the same time it will be difficult 
for him to distinguish large or distant objects, in consequence 
of the field of vision being more or less interrupted and dimin- 
ished. But sight is not generally entirely lost until the optic 
nerve elements have become atrophied. Nor is the injury to 
vision always proportionate to the changes observed in the 
fundus. Tolerable, and even excellent, vision may frequently 
be obtained after serous and hemorrhagic effusions have taken 
place, and even after fatty degeneration has occured, as these 
products are all capable of being absorbed. The affected 
portions of the retina, however, rarely if ever become perfectly 
normal. Permanent changes in both the choroid and retina 
occur under the most favorable circumstances, and some impair- 
ment of vision is always to be expected. 

Treatment. — The treatment of exudative retinitis is 
almost identical with that of cedema retinae, (which see). So 
long as improvement can result from increased absorption, 
benefit may be expected from the administration of Mercurius, 
especially the Corrosivus. This remedy has frequently been 



SYPHILITIC RETINITIS. 25 1 

found very effectual in promoting the absorption of patches of 
exudation, and in clearing up the visual field, the results being 
especially favorable when the disease is of syphilitic origin. 
(See Retinitis syphilitica). Hemorrhagic effusions are often 
quickly absorbed under the use of Belladonna, Crotalus and 
Lachesis, especially the latter. (See Retinitis apoplectica). 
Other remedies will be found under the nephritic variety, 
(which see). When the disease has existed a long time, and 
the choroid and retina are already much atrophied, of course 
but little improvement can be expected. In this case, it is gen- 
erally advisable to confine our treatment chiefly to the employ- 
ment of such measures as are best calculated to preserve the 
existing vision ; and for this purpose especial attention should 
be paid to the patient's health, and to the observance of suita- 
ble hygienic rules. Great care should also be taken to guard 
against a renewal of the inflammation, by avoiding any of the 
known causes, such as exposure of the eyes to bright light, 
etc. Should relapses occur, they will require to be treated 
according to specific indications, having reference more espec- 
ially to the particular forms they may be found to assume — 
as, for example, the inflammatory or hemorrhagic — and to the 
causes which may be supposed to give rise to them. 

3.-SYPHILITIC RETINITIS. 

This is a peculiar form of diffuse retinitis, occuring in 
persons whose constitutions have become tainted with secon- 
dary syphilis. Authorities differ as to the diagnostic value of 
its symptoms, Wells asserting that it is occasionally possible 
to diagnose the nature of the malady from the ophthalmo- 
scopic appearances alone, while Stellwag claims that the disease 
has no peculiar symptoms, but that its syphilitic nature is 
indicated solely by the presence or previous existence of the 
symptoms of constitutional syphilis. We shall find that while 



252 PRACTICE OF MEDICINE, 

the former statement is substantially true, it will frequently be 
impossible to clear up the diagnosis until we have obtained a 
knowledge of the history and constitutional condition of the 
patient. 

SYMPTOMS. — At first there are no characteristic symptoms. 
There is generally more or less venous hyperaemia, but this is 
sometimes only partial. As in simple serous retinitis, the 
optic disc is slightly swollen and its margin rendered some- 
what indistinct by the serous infiltration, which gives to the 
disc and surrounding retina the appearance of being covered 
with a delicate bluish-grey veil or mist. The opacity, which 
is often extremely faint, is most pronounced along the course 
of the vessels and in the vicinity of the optic disc, where it is 
distinctly striated. Small, glistening white points generally 
occur in the region of the macula lutea, which frequently 
disappear and reappear every few days, accompanied with 
corresponding changes in the vision. In this region, also, we 
sometimes find the peculiar reddish-brown tint, or copper colon 
so characteristic of syphilis. Occasionally we meet with white 
spots or patches, either isolated or in the form of irregular 
stripes, which, being seated in the innermost retinal layers, 
may so compress some of the vessels as to give them the 
appearance of white tendonous lines, or bands. Neither the 
white spots, nor the punctated appearance in the region of the 
macula lutea, are pathognomonic symptoms, as they both 
occur in nephritic retinitis ; but in the latter affection, in addi- 
tion to other peculiarities, they are readily distinguished by 
being of a brighter and more glistening aspect. (See Retinitis 
albuminurica). 

Syphilitic retinitis is frequently complicated with choroid- 
itis, and sometimes with irido-choroiditis and keratitis punctata, 
or with syphilitic iritis. Not unfrequently it follows one or 
more attacks of iritis. According to Stellwag, it is peculiarly 
apt to occur if, during convalescence from specific iritis, or 



SYPHILITIC RETINITIS. 253 

before entire removal of the disease, the eye is exposed to 
functional sources of injury. 

Hemorrhagic effusions sometimes occur, but they are 
usually small and insignificant ; occasionally, however, they 
are both numerous and extensive. They may be seated in 
any of the layers of the retina, or upon its external surface, 
between it and the choroid. The latter membrane frequently 
undergoes extensive changes, consisting chiefly in atrophy of 
the epitheliel layer and aggregation of the pigment cells, in 
the form of small black spots interspersed with little grey 
points ; or the atrophic changes may extend still deeper, and 
involve the stroma of the choroid, giving rise to large grey 
patches, bordered with pigment, through which the choroidal 
vessels may be seen. 

Vision is often greatly impaired ; and so rapidly does the 
sight diminish, that the course of only two or three weeks we 
have known the patient to be unable to read No. "L," Snellen. 
As a matter of course, the disturbance of vision is greatest 
when the region of the macula lutea is affected ; and, as already 
stated, the fluctuation frequently corresponds with changes 
which occur in the punctiform opacities of that region. The 
visual field is only slightly diminished, but photopsies, and 
that peculiar symptom, micropsia, are of frequent occurrence. 
(See Exudative Retinitis. — Note). 

PROGNOSIS. — Although, as a rule, the disease progresses 
very slowly, and is subject to frequent relapses, the nerve 
elements of the retina are not apt to be affected, and hence the 
prognosis is generally favorable. In case, however, there 
should be much hypertrophy of the connective-tissue element, 
the latter may so press upon the nervous structure of the retina 
as to give rise to more or less atrophy and permanent impair- 
ment of vision. Moreover, the functional condition of the 
retina is liable to be greatly injured by the frequent relapses to 
which the disease is subject. 



254 PRACTICE OF MEDICINE. 

Treatment. — The remedies which have proven eminently 
curative in this affection, are Merciirins corrosivus and Kali 
hydriodicum. They may be used either singly or in alterna- 
tion, as may best suit the particular indications ; and if the 
patient is brought under their influence at an early period of 
the attack, the disease will generally be found to yield in the 
most satisfactory manner. But if the inflammation has already 
given rise to extensive tissue changes, but little good can be 
expected of any internal treatment, especially if the nerve 
elements are implicated. We notice, however, that Asafcetida, 
Arum, Cinnabaris, Petroleum, Thuya, and a few other remedies, 
have been recommended for this form of retinitis, and they 
may prove serviceable in some cases, provided the specific 
indications correspond with the constitutional as well as the 
local symptoms ; for we confess that we have but little faith 
in any but specific constitutional remedies in this affection. 

4.-NEPHRITIC RETINITIS. 
RETINITIS albumin urica, in bright's disease. 

This form of diffuse retinitis derives its name from the 
fact that it occurs in connection with Bright's disease of the 
kidney, and that its ophthalmoscopic symptoms are, in many 
cases, so peculiar and constant, as to enable us, from the retinal 
appearances alone, to determine with certainty the coexistence 
of the kidney affection. Having in the preceding sections 
described the common characters of diffuse retinitis with 
sufficient fullness, we shall give but a brief sketch of the re- 
maining varieties of retinitis, confining our remarks chiefly to 
the more important and characteristic. 

Symptoms. — The symptoms of nephritic retinitis are, for 
the most part, similar to those of the syphilitic variety; the 
chief difference being that they are generally much more 
strongly defined. Thus, the optic disc is more swollen, and 



NEPHRITIC RETINITIS. 255 

its margin rendered more indistinct, by the serous infiltration, 
which, extending for some distance beyond the disc, presents 
the appearance of a bluish-grey or reddish-grey veil spread 
over the fundus, and conceals to a greater or less extent the 
details of the underlying choroid. The disc and surrounding 
retina generally exhibit a distinctly striated appearance, which 
is chiefly due to hypertrophy and sclerosis of the connective 
tissue element. The retinal veins are enlarged, dark, and 
somewhat tortuous ; but the arteries are normal, or slightly 
contracted. Dark and light spots frequently appear in the 
course of the vessels, in consequence of the varying depths of 
the infiltration. The latter is sometimes so great, especially 
in the vicinity of the optic nerve, as to render the optic disc 
quite swollen and prominent, and conceal more or less com- 
pletely the retinal vessels. Hemorrhagic effusions also take 
place in different portions of the retina, and these are frequen- 
tly numerous and extensive. This is, no doubt, partly due to 
disease of the vascular coats, but chiefly to disturbances in 
the general circulation arising from hypertrophy of the left 
ventricle, which is generally present in Bright's disease, and to 
congestion of the retinal circulation caused by the swelling of 
the optic nerve. 

But the most characteristic symptoms of nephritic retinitis 
are met with at a more advanced state of the affection. We 
then notice in the region of the macula lutea small, white, 
glistening spots, presenting more or less of a stellate figure, 
the characteristic appearance of which may afterwards be lost 
in consequence of their becoming merged in the general exuda- 
tion. We also observe a broad, glistening white band around 
the optic entrance, but separated from it by a zone of greyish- 
brown infiltration, the outer border of which is very irregular, 
and broken up into circumscribed patches of exudation, or 
extended along the retinal vessels towards the periphery, 
especially on the inner side of the retina. At an earlier 



2 $6 PRACTICE OF MEDICINE. 

period, or in less characteristic cases, these symptoms are less 
prominent, the retina in the vicinity of the optic disc appearing 
almost normal, and the peculiar white exudation, instead of 
forming a broad, white ring about the optic disc, lying in scat- 
tered patches, or extending along the course of the vessels. 
Even in these cases, however, the exudation in the region of 
the yellow spot has more or less of a stellate or streaky 
appearance, characteristic of the renal affection. 

The pathological changes just noticed are found to be due to 
fatty degeneration of the cellular and connective tissue elements 
of the retina, especially the latter, which, in the region of the 
macula lutea, are so arranged as to converge towards the 
centre of the yellow spot, and hence the peculiar stellate 
appearance at that point. The striated appearances are due, 
on the other hand, to sclerosis of the optic nerve fibres, and, 
though much less conspicuous, are of far greater importance 
than those arising from fatty degeneration, which, unlike the 
former, are capable of being absorbed. Similar changes take 
place in the coats of the retinal vessels, and also in the chorio- 
capillaris, in consequence of which the diameter of both the 
choroidal and retinal vessels is more or less diminished. 

The sight is usually very much impaired, central vision 
being the most, and peripheral the least, deteriorated. The 
field of vision is but slightly if at all contracted, but it gener- 
ally contains extensive gaps corresponding to the pathological 
changes above noted. Sudden attacks of amaurosis sometimes 
occur from uraemic poisoning, but these are easily distinguished 
from the loss of vision arising from inflammatory changes in 
the retina, which is gradually progressive, besides being accom- 
panied by other symptoms of uraemia, such as headache, 
vertigo, sickness, convulsions, loss of consciousness, paralysis, 
etc. Although frequently attended with symptoms of derange- 
ment of the digestive functions, such as anorexia, nausea, 
sickness, etc., the impairment of vision is often the first symp- 



NEPHRITIC RETINITIS. 257 

torn that attracts the attention of the patient ; and it is not 
perhaps until an opthalmoscopic examination reveals the true 
nature of the complaint that the disease of the kidney is sus- 
pected. As a general rule, however, nephritic retinitis does not 
appear, or is not recognized, until the kidney disease is fully 
developed, and is most frequently met with in the later stages 
of the chronic affection, after amyloid degeneration has set in. 

ETIOLOGY. — The nature of the connection between neph- 
ritic retinitis and Bright's disease of the kidney, is not known. 
By some, the disease of the retina is supposed to be due to 
the congestion arising from hypertrophy and dilatation of the 
left ventricle, which is a common accompaniment of nephritic 
retinitis. This view would seem to be supported by the fact 
that hemorrhagic extravasations are not only of constant 
occurrence in this form of the affection, but appear at the very 
commencement of the disease. Others, again, refer the 
disease to mal-nutrition of the retina caused by the presence 
of urea in the blood. The retinitis and albuminuria are both 
observed in the later months of pregnancy, the kidney affection 
being dependent, no doubt, as suggested by Virchow, on 
mechanical obstruction of the renal circulation. They also 
occur after scarlatina, cholera, pyaemia, typhoid fever, etc., and 
then the retinitis is referable to the coexisting albuminuria. 

PROGNOSIS. — Nephritic retinitis very rarely results in 
complete blindness, and, on the other hand, normal vision is 
seldom regained after extensive pathological changes have 
taken place in the substance of the retina. When these 
changes are due simply to fatty degeneration of the connective 
tissue elements, the patches may be absorbed and vision re- 
stored ; but when atrophy of the optic nerve, or sclerosis of the 
optic nerve fibres, ensue, vision is permanently impaired. 
Those cases, on the contrary, that are secondary to the exan- 
themata, or that occur in advanced pregnancy, or after the 
excessive use of spirituous liquors, etc., admit of the sight 
being fully restored. 



258 PRACTICE OF MEDICINE. 

TREATMENT. — This should, of course, be chiefly addressed 
to the kidneys. For this reason we have more confidence in 
Phos. ac, and Plumb., in these cases, than in any other reme- 
dies, but the following have also been recommended : 

In acute nephritis : Canth., Chelid., Kali acet., Terebinth. 

In chronic nephritis : Ars., Hepar, Phos. ac, Sulph. 

In fatty degeneration: Ars., Canth., Phos. 

In granular dege7ieration : Ars., Colch., Plumb. 

/;/ amyloid degeneration: Ars., Phos. ac, Sulph. 

For urcemic symptoms: Ferr., Opi. 

From alcoholic drinks: Ars., Nux v. 

In pregnancy: Apis, Colch., Gels., Kal., Merc. cor. 

In scarlatina: Apis, Ars., Apoc, Hell., Merc 

5.-LEUCJEMIC RETINITIS. 

Comparatively little is known concerning this somewhat 
rare form of retinitis. It was first described and figured by 
Liebreich, in 1861, but its chief characteristics were first point- 
ed out by Becker and Leber, in 1869. 

Symptoms. — The chief characteristic symptoms of leucae- 
mic retinitis are : a pale orange-yellow hue of the fundus, due 
to an excess of the white blood corpuscles, and a pale pinkish 
color of the retinal vessels, especially the veins, which are often 
dilated and tortuous. The optic nerve entrance is also pale 
from the same cause, and its margin is obscured by a serous 
infiltration which extends a considerable distance from the 
disc, in the vicinity of which the retina presents the usual 
striated appearance. Small extravasations of blood likewise 
occur in different parte of the fundus, but they, also, are of a 
pale reddish color; whilst along the course of some of the 
blood-vessels, and in the region of the macula lutea, are seen 
white stripes and spots, due to an extravasation of the color- 
less blood corpuscles, as first shown by Leber. The latter, in 



LEUCjEMIC RETINITIS. 259 

his dissections, was unable to verify the observation of Reck- 
linghausen relative to a varicose and hypertrophied condition 
of the optic nerve fibres, but he satisfied himself thattherewasnot 
a trace of fatty degeneration of the retina, as in retinitis albumin- 
urica. In some cases, more or less atrophy of the retina has 
been observed, the result of pressure arising from previous 
intra-ocular hemorrhages. 

Treatment. — This, to be of benefit, should be addressed 
to the coexisting leucocythaemia. In the absence of any 
experience, we would suggest a trial of the following remedies: 
Ars., Calc, Chin., Ferr., Nat. m., 01. jec, Phos. ac. 

6 -RETINITIS APOPLECTICA. 

Hemorrhagic effusions are not, as we have seen, peculiar 
to this form of retinitis, comparatively small extravasations 
taking place occasionally in nearly every variety of the affec- 
tion ; but hemorrhagic retinitis, so-called by way of eminence, 
is distinguished chiefly by an extreme tendency to hemorrha- 
gic effusions into the different layers of the retina. 

Symptoms. — In retinitis apoplectica there is more or less 
serous infiltration of the optic nerve and retina, but no exuda- 
tive or degenerative changes, such as are common to other 
forms of retinitis. Nor is the oedema generally very marked, 
but only sufficient, in most cases, to render the disc slightly 
indistinct, and its margin somewhat irregular and obscure. 
The veins, on the other hand, are dark, tortuous, and very 
much enlarged ; while here and there are seen numerous 
extravasations of blood, which, by overlying the retinal 
vessels, frequently interrupt their continuity. The arteries are 
more normal in their appearance, but more or less contracted, 
and in some cases, particularly in the vicinity of the optic 
disc, are changed into narrow, tendon-like bands. 

The hemorrhagic effusions may occur in any portion or 
layer of the retina, and even in the optic disc itself ; but, for 



260 PRACTICE OF MEDICINE. 

obvious reasons, they occur most frequently along the course of 
the blood-vessels, between the inner and outer layers of the 
retina, often pushing aside the elements of the latter, and mak- 
ing their way to the more superficial layers, especially the cho- 
roidal, towards which they are prone to extend. In these cases, 
the patches of effusion will often be found to be situated be- 
neath the retinal vessels, and to have a more distinctly circum- 
scribed appearance than when seated in the internal portions of 
the retina, where they are generally larger and darker, and 
often hide a portion of the vessels from view. In some cases, 
they break through the internal limiting membrane into the 
vitreous, and give rise to dense opacities. The patches under- 
go very little change in their appearance for a long time, but 
finally the process of absorption sets in, and they gradually 
become lighter and lighter, assuming at last a peculiar greyish 
tint. In some cases, however, instead of undergoing absorp- 
tion, they degenerate into dark, friable masses, giving rise to 
black patches of pigment, often of considerable size. 

Vision is, of course, more or less impaired ; but, unless the 
hemorrhage takes place in the vicinity of the macula lutea, the 
sight is not usually so much injured as the ophthalmoscopic 
appearances would indicate. Sometimes, however, the attack 
is very sudden, and the patient, after experiencing a sensation 
of sickness and vertigo, may become nearly or quite blind 
within a very few moments. The field of vision is generally 
somewhat narrowed, and exhibits, here and there, spots or 
spaces corresponding to the patches of effusion ; or in some 
cases, it may be, to their shadows, as first suggested by Heymann. 

ETIOLOGY. — The disease is frequently caused by disturb- 
ances of the general circulation, such as are met with in cardi- 
ac, hepatic and uterine affections, especially those arising from 
hypertrophy of the left ventricle, disease of the aortic valves, 
and menstrual suppression. It may also arise from tumors, or 
any other impediment to the return of venous blood from the 



RETINITIS APOPLECTICA. 261 

eye, situated within the orbit or cranium. A more frequent 
cause, however, especially in elderly people, is atheromatous or 
fatty degeneration of the coats of the retinal vessels, in which 
case, as Wells observes, the cerebral vessels would be likely to 
be similarly affected. 

PROGNOSIS. — This should be particularly guarded, owing 
to the great tendency of the disease to relapses, which, if fre- 
quently repeated, greatly impair the function of the retina, and 
lead, sooner or later, to atrophic changes in the retina and optic 
nerve. 

Treatment. — The above enumeration of causes shows 
that the treatment should be addressed to them, and to the 
general condition of the patient, rather than to the pathologi- 
cal state of the retina, over which remedies can exert but little 
direct influence. Thus, if the heart is at fault, Cactus, Gel- 
seminum, and other cardiac remedies, will be indicated ; portal 
obstruction will call for Mercurius, Nux v., Podophyllum, etc. ; 
and menstrual suppression will require such remedies as Aco- 
nite, Belladonna, Senecio, Sepia, etc. Phosphorus has been 
recommended for the hemorrhagic diathesis, and Arnica, Cro- 
talus and Lachesis to promote absorption of the extravasa- 
tions. 

7.-KETINITIS PIGMENTOSA. 

PIGMENT DEGENERATION OF THE RETINA. 

Although much diversity of opinion exists regarding the 
pathology of this affection, some regarding it as a peculiar form 
of choroiditis, some referring it to chronic perivasculitis of the 
retinal vessels, and some to chronic inflammation of the retina 
itself, we shall find it most convenient to describe it as retinitis 
pigmentosa, the name by which it is generally known. 

Symptoms. — The disease is chiefly characterized by the 
appearance of numerous spots of black pigment in the inner 



262 PRACTICE OF MEDICINE. 

layers of the retina. These spots are of various forms and 
sizes, most of them having a branched or stellate appearance, 
which has led to their being compared, not inaptly, to bone 
corpuscles. The deposits first make their appearance at the 
periphery of the fundus, generally on the inner or nasal side of 
the retina, and thence gradually extend in opposite directions, 
forming a more or less broad band in the middle zone, leaving 
the central, and perhaps the temporal, portion of the retina 
unaffected ; ultimately, however, the remaining portions of the 
membrane, including the region of the macula lutea, may be- 
come involved in the degenerative changes. The retinal ves- 
sels are often greatly contracted, and their walls thickened, the 
smaller branches being obliterated, or changed into narrow 
tendon-like bands. In many cases, however, the vessels, in 
some parts of their course, instead of being bright and trans- 
parent, look like fine, black lines, owing to the presence of pig- 
ment in their walls. This circumstance, in connection with the 
fact that the pigment is generally deposited along the course 
of the vessels, has led many ophthalmologists to refer the dis- 
ease to degenerative changes in their coats — an opinion which 
seems to be confirmed by a case of Schweigger's, in which, as 
stated by Wells, he found, on microscopical examination, that 
the pigmentation was confined to the retinal vessels, the coats 
of which were thickened and the smaller branches obliterated, 
these changes extending beyond the pigmentation. But the 
choroid, retina, and optic papilla also become degenerated, the 
former being more or less deprived of its pigment epithelium, 
so that its vessels are rendered visible, and the retina under- 
going atrophy of its nerve elements and hyperplasia of its con- 
nective tissue elements. To complete the picture, the external 
limiting membrane of the retina becomes destroyed, and the 
granular layer, being no longer confined, becomes more or less 
mixed with the pigment cells of the epitheliel layer of the 
choroid; and as these find their way more freely into the retina in 



RETINITIS PIGMENTOSA. 263 

some places than in others, they become heaped up, here and 
there, into little black masses of pigment, which give to the 
retina its peculiar tessellated or mottled appearance. 

The subjective symptoms in this affection are no less strik- 
ing than the objective, the disease being characterized from its 
commencement by hemeralopia, or night-blindness, and by a 
marked circular contraction of the field of vision. The former 
is due to a torpid condition of the retina, resulting from an in- 
sufficient supply of blood, in consequence of the diminished 
number and calibre of its vessels ; and the latter arises, in all 
probability, from pigmentation of the retina. As a conse- 
quence of these changes, the patient may be able to see well 
enough in a direct line during the day, or in a bright light ; 
but as soon as night approaches, or the field of vision is less 
strongly illuminated, the sight becomes very much impaired. 
When the visual field becomes greatly contracted, the manner 
of the patient is rendered somewhat awkward and uneasy, in 
consequence of his being obliged to roll his eyes about in 
every direction in order. to direct the visual axis upon each 
individual object. As long as the region of the macula lutea 
is unaffected, the sight may remain good for central vision ; 
but as soon as this region is invaded, which generally occurs 
between the ages of 35 and 50, the sight deteriorates, the retina 
and optic nerve gradually become atrophied, and, sooner or 
later, the disease leads to complete blindness. The affection 
generally occurs in both eyes, and is frequently both hereditary 
and congenital. Although the pigment degeneration may not 
appear until after puberty, the disturbances of vision generally 
occur at a much earlier period, and in all cases the disease 
dates from infancy or early childhood. 

ETIOLOGY. — It is evident, from the above, that the etiology 
of this affection is not well understood. As already stated, 
the disease is generally hereditary. It is found to be frequent- 
ly associated with deaf-mutism, and other congenital malform- 



264 PRACTICE OF MEDICINE. 

ations, and is especially liable to occur from the intermarriage 
of relatives. 

PROGNOSIS. — This is very unfavorable, the disease, as al- 
ready stated, ending, sooner or later, in complete blindness. 

TREATMENT. — This can, of course, only be palliative ; 
but, if proper attention is paid to the general health, and the 
eyes guarded against all injurious influences, undue exertion, 
etc., the course of the disease, which is always very slow, may 
be such as not to produce blindness for many years. Kali 
hydriodicum, Mercurius corrosivus, and a few other remedies, 
have been recommended, and may, in some cases, prove tem- 
porarily beneficial ; but care should be taken not to push them 
beyond the point of healthful reaction, as their continued use 
has sometimes led to rapid deterioration of the central vision. 

ART. XIV. — NEURITIS OPTICA. 

Inflammation of the optic nerve, according to Stellwag, 
may be either partial or general ; may be limited to a few bun- 
dles, or embrace its entire thickness ; may be confined to the 
orbital or cranial portion of the nerve ; may embrace the en- 
tire nerve of one or both eyes ; may extend from the retina 
along one or both nervous tracts to the corpora geniculata 
{neuritis ascendens) ; or it may originate within the cranium 
and descend to the optic papilla {neuritis descende?is) ; in short, 
it may assume a great variety of forms and degrees, depending 
chiefly upon its anatomical relations. A certain degree of 
optic-neuritis is generally associated with different forms of 
retinitis, and has already been described. We shall here treat 
only of the idiopathic affection, of which there are two princi- 
pal forms, namely, (1) ascending, and (2) descending optic-neu- 
ritis. 



PRACTICE OF MEDICINE. 265 

1.-ASCENDIN& OPTIC-NEURITIS. 

ENGORGED PAPILLA, ISCILEMIA OF THE DISC. 

SYMPTOMS. — This form of optic-neuritis begins at the 
optic disc and extends upwards along the course of the nerve, 
but generally stops short at the lamina cribrosa. It is chiefly 
characterized by great oedema and swelling of the papilla — 
which, however, may be only partial — by numerous and exten- 
sive extravasations of blood within and around the disc, and 
by great enlargement and tortuosity of the retinal veins, which 
are dark and engorged with blood, while the arteries, on the 
other hand, are very much contracted, and sometimes almost 
entirely empty. 

Etiology. — The engorgement of the papilla is generally 
due to an obstruction in the central vessels of the retina, caused 
by tumors, or other diseases, within the orbit or cranium. This 
obstruction soon gives rise to oedema and swelling of the optic 
nerve, hypertrophy of the connective tissue elements, and, 
finally, to more or less inflammation of the optic nerve fibres 

The researches of Schwalbe, Schmidt, and other recent ob- 
servers, have thrown new light upon the etiology of this affec- 
tion, and have so far disproved the old notion that the engorg- 
ed papilla is generally due to certain cerebral conditions, which 
impede the venous circulation of the optic nerve by an increase 
of intra-cranial tension, or by direct pressure upon the cavern- 
ous sinus, as to render it highly probable that the engorgement 
is due rather to a veritable dropsy of the optic nerve sheath, 
caused by the passage of the arachnoidal fluid between the ex- 
ternal and internal sheaths of the optic nerve to the lamina 
cribrosa and papilla, where it is arrested, and gives rise to more 
or less strangulation and swelling. The congestion and conse- 
quent oedema are, of course, still further increased by the un- 
yielding scleral ring surrounding the swollen papilla. Manz 
thinks that dropsy of the sheath, and consequent engorgement 



266 PRACTICE OF MEDICINE. 

of the papilla, may occur, not only in cerebral affections, ac* 
companied by serous effusions, but by any cause, such as an 
intra-cranial tumor, capable of displacing the normally exist- 
ing arachnoidal fluid, and forcing a portion of it into the sheath 
of the optic nerve. 

Mixed forms of optic-neuritis frequently occur, in which 
the symptoms of engorged papilla are not so pronounced and 
characteristic as above represented, but which shade off, as it 
were, into those of 

2 -DESCENDING OPTIC-NEUEITIS. 

NEURO-RETINITIS, NEURITIS DESCENDENS. 

Symptoms. — This form of optic-neuritis, as its name 
indicates, commences extra-ocularly, the inflammation extend- 
ing downwards to the optic papilla. The swelling and 
hyperaemia of the disc are much less than in the engorged 
papilla, and the veins are less dilated and tortuous ; the 
arteries, on the other hand, especially those of the retina, are 
generally very much contracted. The optic disc is reddish 
and swollen, its outline indistinct and more or less obscured by 
hemorrhagic effusions having a striated appearance, some of 
which are only apparent, consisting of newly-developed and 
closely arranged microscopic blood vessels. The optic disc 
and retina are diffusely clouded, the latter somewhat exten- 
sively, constituting what is called nearo-retinitis. White spots 
sometimes appear in the region of the macula lutea, which 
renders the disease liable to be mistaken for nephritic retinitis; 
but, as pointed out by Von Graefe, the arrangement of the 
spots in neuro-retinitis is different, being situated much nearer 
to the optic disc ; moreover, the oedema of the retina in the 
vicinity of the disc is greater, the swelling of the optic nerve 
is also greater, and the veins are larger and more tortuous. 
(See Nephritic Retinitis). 

The sight is often much impaired, but the diminution of 



DESCENDING OPTIC-NEURITIS. 267 

vision does not always correspond to the extent of the morbid 
changes, being in some well-marked cases of optic neuritis 
perfectly normal. Occasionally, however, the sight diminishes 
very rapidly, so that in the course of a few hours or days the 
patient may be unable to distinguish light from darkness. In 
most cases, the field of vision is more or less contracted ; and 
this condition is generally associated with a sluggish and 
dilated state of the pupil. 

A great variety of subjective symptoms are met with in 
different cases, such as headache, vertigo, loss of memory, 
vomiting, impairment of the special senses, epileptic attacks, 
paralysis, etc. These symptoms generally point to a cerebral 
origin of the neuritis, and are often the occasion of much 
suffering; the headache, especially, is often very severe and 
protracted, and generally extends over the whole head. The 
patient is also frequently annoyed with photopsies and chrom- 
opsies, due chiefly, no doubt, to disturbances in the circulation. 

ETIOLOGY. — Optic-neuritis frequently originates in cere- 
bral meningitis, the inflammation extending to the optic nerve, 
and giving rise to descending neuritis. It has also ocurred in 
connection with cerebro-spinal meningitis, with intra-cranial 
tumors, abscesses, syphilitic deposits, hydatid cysts, blood-clots, 
etc. According to Jackson, optic-neuritis should be looked 
for in every form of cerebral disease, especially those that give 
rise to cerebral fever. In some cases the disease appears to 
be hereditary. The disease also occurs in young and delicate 
females, and is then generally traceable to some menstrual 
disturbance, or disorder of the central nervous system, such as 
spinal irritation, chorea, etc. 

PROGNOSIS. — This is generally unfavorable, most cases of 
optic-neuritis resulting sooner or later in atrophy of the nerve 
and loss of vision. ** The prognosis is said to be more favorable 
in the case of children than in adults ; also, that acute and 
rapidly progressing cases afford, as a rule, a more favorable 



268 PRACTICE OF MEDICINE. 

prognosis than the chronic and gradual. So far as the general 
prognosis is concerned, those are especially favorable in which 
the affection is due to some temporary and removable cause, 
such as menstrual irregularities, spinal irritation, etc. But 
when the brain is affected, the question of vision is merged in 
the more important one of saving the patient's life, and then 
the case belongs to the domain of general practice. 

Treatment. — More good will generally be accomplished 
by suitable hygienic measures, and by attention to the general 
health, than by any specific treatment of the eye symptoms. 
Whenever practicable, the removal of the cause, whether it be 
an inflammation or tumor in the orbit, or functional disturban- 
ces of the circulation, such as arise from menstrual irregularities, 
will generally give the most prompt and lasting relief. In the 
great majority of cases, however, the treatment will of necessity 
be merely palliative, and will require to be mainly directed to 
the relief of the patient's sufferings. 

In the absence of any precise indications, the following 
list of remedies is suggested, the selection to depend upon the 
general action of the remedy and the exigencies of each 
particular case: — Apis, Ars., Aur., Bell., Bry., Cact., Cim., 
Collin., Con., Croc, Gels., Kali iod., Lach., Lept., Merc, Nux v. 
Phos., Puis., Spig., Sulph., Zinc. 

ART. XV. — INFLAMMATION OF THE ORBITAL TISSUES. 

Under this head we shall describe, very briefly, (i) inflam- 
mation of the capsule of Tennon (Bonnet's capsule); (2) 
inflammation of the cellular tissue of the orbit ; and (3) 
periostitis of the orbit. 



PRACTICE OF MEDICINE. 269 

1 -CAPSULITIS TENONII. 

INFLAMMATION OF THE CAPSULE OF TENNON. 

The ocular capsule, known as the capsule of Tennon or 
Bonnet, is sometimes subject to inflammation. 

SYMPTOMS. — There is, generally, considerable pain in and 
around the eye, and in some cases it is severe, extending to the 
face and corresponding side of the head. The globe is some- 
what protruded and its motions impaired, but the most marked 
symptom is a greater or less degree of chemosis, the ocular 
conjunctiva being red and swollen, and accompanied with con- 
siderable episcleral injection. The eyelids, also, are somewhat 
swollen and inflamed, but the conjunctival secretion 
is but little if any increased. At the same time, the cornea, 
iris and other tissues of the eye remain unaffected. Choroid- 
itis and hyalitis are said in some cases to attend or precede 
the affection, but as a general rule vision continues unimpaired 
throughout the progress of the case. The disease usually 
runs a slow but safe course, the effusion between the capsule 
and sclera being absorbed. 

ETIOLOGY. — Cold and erysipelas are said to be the chief 
causes, especially the former. It may also be of traumatic 
origen, as in irido-choroiditis following cataract operations, or 
the inflammation sometimes excited by the operation for 
strabismus. 

Treatment. — When the disease is of catarrhal or rheu- 
matic origin, warm fomentations will be appropriate, and 
will generally give great relief. If on the other hand the 
disease is due to trauma, cold applications will be required. If 
the inflammation is very severe, Aconite and Belladonna, 
either singly or in alternation, may be employed, aided, if 
necessary, by a Belladonna lotion or ointment. 



270 PRACTICE OF MEDICINE. 

2.-CELLULITIS ORBITJE. 

INFLAMMATION OF THE CELLULAR TISSUE OF THE ORBIT. 

SYMPTOMS. — Inflammation of the orbital cellular tissue 
is generally of a very acute character, and, as in other forms 
of cellulitis, soon terminates in suppuration and abscess. 
Owing to the unyielding nature of the cavity in which the 
parts are lodged, the inflammatory swelling, which is always 
very great, and especially so after suppuration has set in, gives 
rise to the most intense and agonizing suffering within the 
orbit, the pain extending to the surrounding parts and often 
to the whole head. The eyelids are red, hot, and very much 
swollen, the conjunctivae much injected, and accompanied in 
most cases with great chemosis, in the centre of which the 
cornea is deeply imbedded. The swelling of the orbital 
tissues causes more or less protrusion of the globe, and 
although this is not at first very perceptible, it gradually 
increases, until at last the palpebral are unable to cover the 
organ, and the latter stands out, more or less, from between 
them. Pressure upon the globe, or any attempt to move it, 
excites intense pain, and therefore the patient keeps the eye per- 
fectly still. As suppuration occurs the pain slightly abates, 
becomes intermittent and throbbing, and is attended with 
manifest rigors. These symptoms are generally accompanied 
with considerable fever, especially at night ; and if the inflam- 
mation extends to the brain, delirium, vomiting, and other 
cerebral symptoms, ensue. If the suppuration is extensive 
the pus ultimately makes its way to the surface, either present- 
ing at the orbital margin, or under the conjunctiva where it 
passes from the lid to the globe. In some cases the inflamma- 
tion spreads to the globe, and then the symptoms of panoph- 
thalmitis are added to those already described. (See Suppurative 
Choroiditis. Even when the suppuration is confined to the 
orbital tissues, the vision is often greatly impaired, either by 



CELLULITIS ORBITS * IJt 

the stretching of the optic nerve or by the pressure upon it, 
and the field of vision is also more or less contracted. The 
retinal veins are frequently dilated and tortuous, the retina and 
optic disc more or less infiltrated with serum, and when the 
disease is protracted it sometimes gives rise to optic-neuritis. 

But inflammation of the orbital cellular tissue is some- 
times far less acute, and may even be of a chronic character. 
In these cases the symptoms are proportionably less severe. 
Matter forms and makes its way to the surface more slowly, 
the eye gradually protrudes from between the lids, which 
become somewhat red and swollen, and finally perforation 
occurs and the pus is evacuated. 

ETIOLOGY. — Orbital cellulitis may be induced by sudden 
atmospheric changes, by exposure to cold and wet, or by other 
physical causes. It may also arise from the extension of 
inflammation from neighboring parts, as in purulent conjunc- 
tivitis, panophthalmitis, erysipelas of the head and face, etc. 
Occasionally the inflammation supervenes upon severe consti- 
tutional diseases, such as typhus fever, purperal fever, pyaemia, 
etc. But the most frequent causes are of a traumatic charac- 
ter, such as penetrating, contused, or incised wounds of the 
orbital tissues, injuries received from the lodgement of foreign 
bodies in the orbit, operations upon the lachrymal sac, eyelids, 
eye, etc. 

PROGNOSIS. — This varies according to the nature and 
extent of the complications. If, as is not unfrequently the 
case, the cellulitis becomes complicated with periostitis of the 
orbit, it may result in caries or necrosis of the latter, in which 
case the pus may find its way into the antrum Highmorianum, 
or into the cranium ; or the inflammation may extend back- 
ward along the periosteum directly to the membranes of the 
brain, and give rise to cerebral inflammation or abscess. Life, 
as well as vision, may also be jeopardized by inflammation and 
suppuration of the globe, or by such an impairment of the 
general health as to preclude recovery. 



272 PRACTICE OF MEDICINE. 

Treatment. — During the first stage, or before suppura- 
tion sets in, cold compresses should be employed, the latter 
being conjoined with the internal use of Aconite, unless the 
symptoms call for some other remedy, such as Apis, Bell., Bry., 
Rhus, etc. But if suppuration has already set in, warm appli- 
cations, such as fomentations and poultices, will be required. 
The latter will generally be found to be the most convenient, 
not only for the purpose of promoting suppuration, but to 
facilitate the discharge of pus:, which should always be evac- 
uated at the earliest possible period, either through the 
conjunctiva, or if this is impracticable, then through the lid 
itself. The internal remedies best adapted to this stage are : 
Ars., Hep., Lach., Merc, Sil., Sulph. 

If there should be any doubt as to the presence of pus in 
the orbital cavity, the upper lid may be retracted, and a small 
exploratory incision made, by passing a narrow-bladed knife 
(PL I. Fig. 13) through the conjunctiva, above the upper surface 
of the globe, into the orbit, and if pus oozes out, the opening 
should be enlarged so as to permit of its free evacuation. In 
order to avoid injuring the globe, care should be taken to 
direct the edge of the instrument slightly upward in making 
the incision. A warm emollient poultice should then be 
applied, and if this fails to keep the opening patulous, the lips 
of the wound should be carefully separated with a probe, or, ii 
necessary, a small tent may be inserted, being careful to remove 
it at least once a day. If the sinus is a long one, and 
especially if it seems indisposed to heal, a mild astringent 
lotion should be injected every time it is dressed. A careful 
examination should also be made from time to time, in order 
to discover the condition of the bone, and if necrosis is found 
to exist, the sequestrae should be removed as fast as they may 
become detached. 

Diet and Regimen. — The general health of the patient 
should receive careful attention, and the diet should be of the 



PERIOSTITIS OF THE ORBIT. 273 

most nutritious and liberal character. Long-continued suppu- 
ration may demand the use of malt liquors, especially if the 
patient's health has been already undermined by serious ill- 
ness. 

3. -PERIOSTITIS OF THE OBBIT. 

Orbital periostitis may be either acute or chronic. The 
former is generally attended by high inflammatory 

Symptoms. — The symptoms of acute orbital periostitis 
are similar to those of orbital cellulitis, except that they are 
generally somewhat less severe, and the protrusion of the globe 
is more or less oblique, as respects the antero-posterior diame- 
ter of the ball, instead of being direct. Moreover, the move- 
ments of the globe are less restricted in some directions than 
in others, owing to the periostitis being confined to a particu- 
lar part of the orbit. Where the sensations of the patient and 
the obliquity of the globe are not sufficient to determine the 
seat of the disease, it may frequently be detected by gently 
pressing the globe back into the orbital cavity in different di- 
rections, the pain and swelling corresponding to the seat of 
the inflammation. The cellular tissue, as well as the bone 
itself, also become more or less inflamed, the former sometimes 
to a great extent, in which case pus is formed in considerable 
quantity, causing marked protrusion of the eye, and a corre- 
sponding limitation of its movements. 

In chronic periostitis, the symptoms are the same as in the 
acute form, but much less severe. Thus, the orbital and circum- 
orbital pain, the redness and swelling of the lids, the chemosis, 
the conjunctival and episcleral injection, and the ocular protru- 
sion, are generally less pronounced, while the course of the 
disease is more insidious and protracted. The pain, which is 
usually most severe at night, is always increased when pressure 
is made on the globe in the direction of the swelling, which' 



274 PRACTICE OF MEDICINE, 

may often be detected in this manner. More or less suppura- 
tion generally occurs, the matter sometimes accumulating be- 
neath the periosteum and separating it from the bone, in which 
case the latter is apt to become necrosed. If this should occur, 
the inflammation or the pus may extend into the frontal sinus, 
or into the cavity of the cranium, giving rise to either menin- 
gitis or abscess of the brain. In other cases, the periosteum 
swells and forms nodes, or tumors, which, after the inflamma- 
tion has run its course, generally disappear, leaving, perhaps, 
only a little thickening of the periosteum ; sometimes, however, 
the tumors ossify and become permanent. 

ETIOLOGY.— Acute periostitis is frequently due to the 
same causes that give rise to orbital cellulitis, and is often as- 
sociated with it. Operations on the lachrymal sac are especially 
apt to give rise to it. So, also, are concussions and injuries of 
the orbit, whether made by blows, by cutting instruments, or 
by the lodgement of foreign bodies within the orbital cavity. 
Sometimes the disease is secondary, the inflammation extend- 
ing from the frontal sinus, or other neighboring cavities. The 
chronic form, on the contrary, is frequently due to syphilis. 
Many cases occur, also, among scrofulous and badly-nourished 
children. 

PROGNOSIS. — Orbital periostitis generally ends in recov- 
ery, though in some cases, especially when the roof of the orbit 
becomes carious, the inflammation may travel tc the brain and 
cause death. In most cases, however, the caries and necrosis 
are limited to the margin of the orbit, resulting, when healed, 
in contraction of the integuments, and, in many cases, causing 
more or less ectropium. But the worst results, so far as the in- 
tegrity of the eye is concerned, are experienced when the pos- 
terior portion of the orbit becomes carious, for this always 
gives rise to extensive suppuration of the orbital tissues, and 
not unfrequently affects the optic nerve, destroying its function 
by inflammation, or so compressing it as to lead to atrophy. 



DACRYO-ADENITIS. 275 

TREATMENT. — Simple periostitis requires similar treat- 
ment to that recommended for inflammation of the cellular 
tissue of the orbit (which see). It is especially important that 
all collections of matter should be evacuated as soon as possi- 
ble after they are detected, and that care should afterwards be 
taken to favor the escape of pus and other morbid products. 
When the disease can be traced to some dyscrasia of the sys- 
tem, anti-scrofulous or anti-syphilitic remedies will generally 
be indicated, such as Cist, c, Kali iod., Kali brom., Merc, pro- 
toiod., Nit ac, 01. jec„ Sulph., etc. 

ART. XVI.— INFLAMMATION OF THE LACHRYMAL APPARATUS. 

Diseases of the lachrymal organs are frequently met with, 
but inflammation of these parts is comparatively rare. Ery- 
sipelatous inflammation frequently occurs at the internal angle 
of the eye, and the attendant swelling, being situated over the 
lachrymal sac, may give rise to symptoms resembling, in some 
respects, those of inflammation of the sac itself ; but it gener- 
ally subsides without involving these parts to a degree sufficient 
to cause suppuration, or any other unpleasant consequences. 
We shall embrace what we have to say concerning inflamma- 
tory affections of the lachrymal organs under the two heads of 
(1) Dacryo-adenitis, and (2) Dacryo-cystitis. 

l.-DACRYO-ADENim 

INFLAMMATION OF THE LACHRYMAL GLAND. 

SYMPTOMS. — Acute inflammation of the lachrymal gland 
is seldom an idiopathic affection. It is characterized by great 
heat, redness and swelling, such as accompanies the formation 
of acute abscess in other parts. Sometimes the inflammatory 
products are absorbed, and the swelling subsides ; but, in most 
cases, suppuration occurs, and generally continues long after 



2J6 PRACTICE OF MEDICINE. 

the opening of the abscess. The suppurating cavity is com- 
paratively deep, and usually opens and closes several times be- 
fore it becomes permanently healed. In some cases, however, 
the opening remains patulous, and a small fistulous sinus is 
formed, through which the lachrymal secretion continues to 
ooze. But dacryo-adenitis is most frequently of a chronic 
character, and runs a very slow and tedious course. It usually 
manifests itself by the appearance and gradual development of 
an irregular, more or less hard, and immovable swelling at the 
outer and upper portion of the orbit. When the tumor is large, 
it pushes the globe downwards and inwards, and sometimes 
impedes its movements, especially in the opposite direction. 
The tumor is not generally painful, nor sensitive to the touch ; 
but, if the swelling is of considerable size, or if the inflamma- 
tion is at ail acute, it maybe both painful and tender, especially 
on pressure. In some cases the upper lid is red and cedema- 
tous, the palpebral conjunctiva injected and somewhat swollen, 
and the ocular conjunctiva, perhaps, chemotic. Occasionally, 
both glands become inflamed at the same time, and then the 
deformity is symmetrical. 

Etiology. — In most cases, dacryo-adenitis is the result of 
a blow, or fall ; but it may also be due to cold, or it may spring 
from chronic inflammation of neighboring parts. 

Treatment. — In the acute form, Aconite, Belladonna and 
Baryta internally, in connection with cold or ice-water com- 
presses externally, will favor resolution of the inflammation ; 
but if suppuration threatens it should be encouraged by the 
use of hot fomentations and poultices, and as soon as pus forms 
it should be let out by making a free incision into the abscess. 
Hepar, Merc, and Silex are the internal remedies most fre- 
quently indicated after suppuration sets in. In the chronic 
form, Bar. iod., Kal. iod., and Phytolacca should be tried ; but, 
if the swelling remains, and especially if it impairs the mobili- 
ty of the eye-ball, or causes its displacement, the tumor should 
be extirpated. 



PRACTICE OF MEDICINE. 277 

2.-DACRY0-CYSTITIS. 

INFLAMMATION OF THE LACHRYMAL SAC. 

SYMPTOMS. — Acute inflammation of the lachrymal sac is, 
when fully developed, a very painful affection — much more so 
than the limited extent of membrane involved would lead us 
to expect ; moreover, there is generally much constitutional 
disturbance, or feverishness, attending the disorder — peculiari- 
ties which are chiefly due, no doubt, to the vascularity of the 
affected membrane, and the unyielding character of the bony 
canal in which the latter is inclosed. A dull, shooting pain is 
first felt in the region of the lachrymal sac, at the inner angle 
of the eye, at which point there appears a small, hard, circum- 
scribed swelling, which afterwards becomes hot, red and tense, 
and so sensitive that the patient cannot bear to have it touched. 
The neighboring parts also frequently become red and swollen, 
the oedema extending to the eyelids and face, and even to the 
temple. The conjunctiva is more or less injected and swollen, 
especially the large fold of that membrane, and there may also 
be some chemosis. The nose generally appears dry and stop- 
ped up, in consequence of the closure of the nasal duct, which 
prevents the passage of fluids into the nostrils. At this time, 
the appearances are such that the disease is liable to be mis- 
taken for erysipelas of the face. This is especially true of 
the lids, which are extensively infiltrated with serum, and are 
red and glistening. But a close examination of the parts will- 
reveal a marked prominence and redness in the region of the 
sac, the circumscribed enlargement of which is also apparent 
to the touch. 

After a time, varying from a few days to as many weeks, 
according to the violence of the inflammation, suppuration of 
the sac occurs ; the swelling becomes still more prominent, and 
if left to itself often bursts and gives exit to pus, or pus 



278 PRACTICE OF MEDICINE. 

mingled with tears and mucus, though the latter do not gen- 
erally begin to be discharged until after the inflammation has 
somewhat receded. After perforation occurs, the pain, 
swelling, and other inflammatory symptoms, rapidly subside ; 
and in the course of a few weeks more, if circumstances favor, 
the opening may heal up, and complete recovery take place. 
Usually, however, the persistent flow of muco-purulent matter 
and tears wholly prevent the closure of the opening, or if not, 
the closure is but temporary, as the inflammation soon relapses, 
and leads again to perforation, and so the process is continued, 
until what is called a fistula lachrymalis, or more properly a fis- 
tula of the lachrymal sac, is established. Sometimes, especially 
in chronic cases, more than one external opening is formed, in 
consequence of the cellular tissue in the vicinity of the sac 
breaking down into small abscesses, which finally open in the 
usual manner by perforation. 

More frequently, however, the inflammation does not 
advance to suppuration and the formation of fistulae. The 
natural secretion, so to speak, of the mucous membrane, 
becomes so altered by the inflammatory process as to resemble 
pus, and in this state either escapes spontaneously through 
the puncta lachrymalia, or is forced out whenever pressure is 
made on the distended sac. The relief thus obtained causes 
the inflammation to recede ; the secretion gradually becomes 
thinner and more natural, and at last changes into clear mucus. 
As the congestion and tumefaction abate, the sac and duct 
again become pervious, the lachrymal secretion takes its 
natural course into the nose, and the disease is at an end. 

ETIOLOGY. — Dacryocystitis is generally a secondary 
affection, being due to an extension of the inflammatory pro- 
cess from the conjunctival or nasal mucous membrane, as in 
granular conjunctivitis, nasal catarrh, periostitis and caries of 
the nasal bones, etc. It is especially apt to occur under these 
circumstances in scrofulous and syphilitic patients. It is 



DACRYOCYSTITIS. 279 

frequently associated with erysipelas, but whether as cause or 
effect is uncertain. It also frequently follows blennorrhea of 
the sac. When idiopathic, it is generally of catarrhal origin. 

TREATMENT. — If seen at the commencement, we should 
endeavor to prevent the formation of an abscess, by the local 
use of cold or ice-water compresses, and the internal adminis- 
tration of such remedies as Aconite, Belladonna, Baryta, etc.; 
but as soon as pus appears in the lachrymal sac, we should try 
to avert perforation, and secure a ready exit for the discharge, 
by slitting the upper canaliculus with Weber's knife, (PI. II, 
Fig. 38), and then, if the opening into the sac is contracted, 
passing the knife into the latter, and dividing its neck. Gentle 
pressure upon the walls of the sac will then cause the free 
escape of its contents, the pus continuing to ooze out of the 
opening, and welling up freely whenever the slightest pressure 
is made upon the swelling. A probe should now be used to 
dilate the nasal duct, so as to restore the passage into the nose. 
But if suppuration has already progressed so far as to render 
perforation inevitable unless otherwise relieved, it is better to 
lay the sac open, by making a free incision into it, in a down- 
ward and outward direction, and thus give exit to the pus. 
A warm-water dressing, or a poultice, should now be applied, 
and the wound kept open until the discharge ceases, which 
will generally occur as soon as the inflammation subsides, and 
the nasal duct is rendered pervious. If the lachrymal pas- 
sages remain closed after the inflammation abates, the canali- 
culus should be divided, and the nasal duct dilated by a probe, 
as already described. The same operative procedures should 
be had recourse to, in case perforation has already taken place. 
If the ulcerated opening fails to heal readily, and becomes 
fistulous, its edges should be stimulated from time to time 
with sulphate of copper, when it will soon close. If, after the 
perforation has healed, the lining membrane of the sac con- 
tinues to secrete muco-purulent matter, the passage should be 



280 PRACTICE OF MEDICINE. 

syringed out daily with a solution of alum or sulphate of zinc, 
of the strength of one or two grains to the ounce of distilled 
water, or a weak preparation of Hamamelis or Muriate of 
Hydrastia, may be used in the same manner. These injections 
will not only clear the sac of irritating secretions, but will 
diminish the discharge by lessening the inflammatory process. 
The injections should be made every day, or every other day, 
as may be found most beneficial ; and, if necessary, they should 
be gradually strengthened as improvement occurs. Any con- 
venient syringe will answer to inject the fluid, but it will 
generally be necessary to first pass a silver canula, by one of 
the canaliculi, through the sac into the duct, and to this the 
nozzle of the syringe should be attached. Or, if preferred, 
we may introduce Spier's lachrymal catheter (PL II, Fig. 39) 
through the inferior punctum and canaliculus, and inject the 
sac through the upper canaliculus, by means of an Anel's 
syringe the injection passing out again through the catheter 
lying in the inferior canaliculus.* If the parts are tense 
and hypertrophied, it may be necessary to facilitate the 
introduction of the tube, by previously dividing the neck of 
the sac and the internal palpebral ligament. This is most 
readily effected by first slitting up the canaliculus with 

Weber's beak-pointed knife, (PI. II, Fig, 38), and after passing 
the point of the instrument quite down into the sac, turning 
its cutting edge forwards and outwards, and incising the 
ligament from within. 

The internal treatment for blennorrhcea of the lachrymal 
passages may be gathered from the following indications : 

Discharge thin and acrid : Alum., Ars., Arum t., Cinnab., 
Merc. 

Discharge thin and bland : Euph., Sil. 

Discharge thick and bland : Calc, Puis. 

Discharge very profuse : Arg. nit., Euc. g., Hepar, Nat. m., 
Merc. 

Obstinate : Calc, Fluor, ac, Petrol., Sil. 

Occasionally useful. — Brom., Calend., {topically), Hydras, 
Kali iod., Lach. Sulph. 



See Am. Horn.. Obs. t vol. viii, p. 360. 



DISEASES OF THE EYE. 28 1 



ART. XVII. — ADDITIONAL THERAPEUTIC INDICATIONS. 

The remedies mentioned in the preceding pages are those 
upon which the author has hitherto chiefly relied in the treat- 
ment of ophthalmic inflammation ; but as the list is in some 
instances somewhat meagre, we have gleaned from our hom- 
oeopathic literature the following additional therapeutic hints, 
which will no doubt be found serviceable in particular cases * 

Agaricus. — Spasmodic action of the muscles of the eye- 
lids and globe ; twitching of the lids, accompanied with great 
heaviness ; twiching and jerking of the eyeballs, with soreness, 
aching, and outward pressure. Spasmodic movements gen- 
erally disappear during sleep, but return on waking. Great 
weakness of the eyes ; vision soon becomes obscured, espec- 
ially for near objects ; everything appears blurred and 
indistinct. 

This remedy has cured muscular asthenopia, with weak- 
ness of the internal recti ; also anaemia of the choroid, retina 
and optic nerve. 

Ailantus gland. — Conjunctivitis, with aching, burning, 
smarting and roughness ; purulent discharge, with agglutination 
of the lids in the morning. 

This new remedy is said to have cured chronic gono- 
rrhoea! ophthalmia. 

Alumina. — Burning sensation in the eyes, with or without 
lachrymation, especially at night ; itching and smarting of the 
lids and canthi ; nightly agglutination ; weakness of the upper 
lids, which hang down as if paralyzed ; conjunctiva red and 
inflamed ; edges of the lids itch and burn ; cilia drop out ; 
photophobia ; squinting, and dimness of vision. 

In blepharitis ciliaris ; trachoma ; muscular asthenopia, 
with weakness of the internal recti ; amaurosis. 
36 



282 ADDITIONAL 

Amy I nit. — Eyes staring; conjunctiva bloodshot; pupils 
dilated ; vision obscured ; chromopsia ; veins of the optic 
disc enlarged, varicose and tortuous. 

In exophthalmic goitre, by olfaction. 

Asafcetida. — Crampy, drawing and boring pains around the 
brows ; stitching and burning pains in the eyes, with dryness, 
and sensation as if sand was in the eye ; pressure in the eyes ; 
heavy feeling in the eyelids, as if sleepy. 

Ciliary neuralgia, keratitis, iritis, irido-choroiditis, and 
retinitis, are said to have been benefited by this remedy, 
especially syphilitic cases. 

Asarum. — Severe burning in the lids, with or without 
watering of the eye; conjunctiva deeply injected ; violent con- 
gestive headache. 

Chronic blepharitis and asthenopia, attended with severe 
headache, are reported as having been cured by this remedy. 

Aurum mnr. — Vascularity and opacity of the cornea ; 
ciliary injection ; photophobia; tearing pains in the globe, 
especially the left ; complete loss of vision. 

Several cases of diffuse keratitis, accompanied with the 
above symptoms, have been reported cured by low attenuations 
of this remedy ; also a case of amaurosis, with great prostra- 
tion, occurring suddenly after a severe attack of scarlatina. 

Baryta tod. — Drs. Liebold and Woodyatt report cases of 
diffuse and obstinate phlyctenular keratitis, in scrofulous 
subjects, successfully treated with this remedy ; the lymphatic 
glands "feel like a string of beans between the muscles." 

Calcarea iod. — Severe ciliary irritation, pain, photophobia, 
lachrymation, spasm of the lids. 

Reported serviceable in nearly every form of scrofulous 
inflammation of the eye, particularly chronic blepharitis, 
phlyctenular and suppurative keratitis, especially when com- 



THERAPEUTIC INDICATIONS. 283 

plicated with enlargement of the glands of the neck and 
throat. 

Cedron. — Eyes protruding ; pupils fixed and dilated ; 
dimness of vision, especially at night ; objects appear red at 
night and yellow in the day time ; pressive and shooting pains 
in the forehead and temples, worse over the left eye. 

Supra-orbital neuralgia, especially when dependent upon 
iritis, choroiditis, and other intra-ocular troubles, appears to 
have been frequently relieved by this remedy. 

Chelidonium. — Violent pressive and shooting pains in the 
eyes ; neuralgic pains in the brows and lids ; feeling of sand 
in the eyes, especially on movement ; redness, burning and 
swelling of the eyelids, with morning agglutination ; yellow- 
ness of the sclerotica ; dimness of vision, with faintness ; 
flickering and brilliant specs before the eyes. 

Intermittent ciliary neuralgia, catarrhal conjunctivitis, 
and rheumatic amaurosis, are reported as having been cured by 
this remedy. 

Cicuta. — Diplopia ; things look black ; eyes protrude, 
with a staring look ; pupils first contracted, then considerably 
dilated ; when standing or walking, the sight vanishes, and 
objects appear to advance, recede, and waver, from vertigo. 

Cicuta has cured double vision, vertigo, blepharitis with 
agglutination of the lids, and photophobia ; but its chief value 
appears to be in spasmodic affections of the eyes and lids. 

Clematis. — Smarting pain in the eyes and in the margins 
of the lids ; burning pain in the lids and canthi ; stitches and 
burning in the inner canthus, with weak sight and lachrymation. 

Chronic blepharitis and conjunctivitis, keratitis, iritis, and 
kerato-iritis, occuring in scrofulous subjects, have been cured 
or greatly benefited by this remedy. 

Comocladia. — Aching soreness in the globes, which feel 
heavy and larger than natural ; painful pressing-out sensation, 



284 ADDITIONAL 

as if something was pressing on top of the eyeballs ; severe 
pain in the balls, extending to the head ; pains increased by 
warmth. 

In ciliary neuralgia associated with asthenopia, and 
chronic iritis. 

Crocus. — Burning in the eyelids ; burning and smarting in 
the eyes, as from smoke ; spasmodic twitching of the lids, 
especially the upper ; aching in the eyeballs, with epiphora, 
worse on reading ; upper lids feel heavy ; pupils dilated ; 
sight obscured, as by a mist, worse for central vision. 

This remedy seems to have relieved a variety of ophthal- 
mic troubles, chiefly menstrual, or occurring in hysterical 
women ; such as nictation, with epiphora ; nightly twitching 
of the lids, with lachrymatfon ; asthenopia, associated with the 
above symptoms, or when attended with a sensation as if the 
patient had been weeping ; pains in the eye and head, occur- 
ring in sclero-choroiditis posterior, etc. 

Crotalus.- — Yellow, sunken appearance of the eyes ; pres- 
sure in and above the orbits ; oozing of blood from the eyes, 
which appear ecchymosed ; frequent vanishing of sight, 
especially in damp weather, or when reading. 

In ciliary neuralgia and amblyopia, occurring in women, 
and aggravated at the menstrual period ; it also appears to be 
indicated in retinal hemorrhages, as first pointed out by 
Dr. Liebold. 

Croton tig. — (Edematous swelling and itching of the 
eyelids ; weakness of the eyes, with lachrymation ; violent 
stinging and burning pains in the eye, with inflammatory 
redness and irritation of the conjunctiva ; violent inflammation 
of the eye occurred on the second day, attended with ulcera- 
tion of the ocular conjunctiva, irritation of the iris with 
contraction of the pupil, conjunctival and episcleral injection, 
profuse lachrymation, photophobia, and violent pains, disturb- 
ing the nights rest. 



THERAPEUTIC INDICATIONS. 285 

Phlyctenular ophthalmia and keratitis, either with or 
without ulceration of the cornea, are said to have yielded 
speedily to this remedy, especially when the characteristic 
eruption also appeared on the lids and face. 

Cyclamen. — Dilatation of the pupils, with obscuration of 
sight ; stupefaction, with sensation of a fog before the eyes. 

Amblyopia, diplopia, hemiopia, and convergent strabis- 
mus, are said to have been relieved by this remedy. 

Fluoric ac — Violent itching in the canthi ; increased 
lachrymation ; sensation as of cold wind blowing in the eyes ; 
vision disturbed by dark, floating opacities. 

Lachrymal fistula, of a years duration, and dark spots 
before the eyes, caused by movable opacities of the vitreous, 
are reported to have been relieved by this remedy. 

Hamamelis. — Painful inflammation of the eyes and lids, 
with extreme congestion ; ecchymosis of the lids ; intra-ocular 
hemorrhage. 

This remedy, used locally as well as internally, has been 
successfully employed in traumatic conjunctivitis, keratitis and 
iritis, caused by burns, splinters, blows, etc.; also in ulceration 
of the cornea, and in internal hemorrhages, especially when 
of traumatic origin. 

Kali bicli. — Conjunctiva deeply injected, with heat and 
uneasiness ; eyelids inflamed and swollen ; papillae of the 
palpebral conjunctiva enlarged ; cornea ulcerated ; photopho- 
bia and dimness of vision. 

Trachoma, pannus, corneal opacities, and rheumatic iritis, 
the latter in a syphilitic patient, have been successfully treated 
by this remedy. 

Kalmia. — Sensation of stiffness in the eyelids, and in the 
muscles around the eyes ; itching in the eyes ; glimmering 
before the eyes, exactly in the axis of vision ; dimness and 
loss of vision, especially on looking down, worse in the 
morning. 



286 ADDITIONAL 

Sclero-choroiditis anterior, asthenopia with stiffness of the 
recti muscles, and retinitis albuminurica, have all been cured, 
or greatly benefited, by the internal administration of Kalmia. 

Lycopus virg. — The chief symptom is a painful pressure 
in the eyeballs. 

Lycopus has relieved protrusion of the eyes, with tumul- 
tuous action of the heart, and is even reported to have cured 
exophthalmic bronchocele. 

Phytolacca. — Burning, smarting and itching in the eyes, as 
if sand were in them, with profuse lachrymation ; dull, heavy 
pain in the eyeballs, worse from motion, light, and reading ; 
an eruption (probably enlarged papillae) on the conjunctiva; 
eyelids cedematous and agglutinated. 

This remedy is reported to have cured catarrhal ophthal- 
mia, with lachrymation and photophobia ; also granular 
conjunctivitis, with circum-orbital pain and soreness ; great 
benefit is also said to have resulted from its internal adminis- 
tration in a case of traumatic suppurative choroiditis, in which 
the lids were enormously swollen, the conjunctiva chemosed, 
and the anterior chamber filled with pus. 

Primus sp. — Lancinating and shooting pains in and around 
the eye, and in the corresponding side of the head ; pain in 
the eyeball as if it were crushed or wrenched ; pain in the 
globe as if it were pressed asunder ; sharp, piercing pains, 
extending to the eye ; aggravation of the pains from motion. 

This remedy not only seems to relieve almost every form 
of ciliary neuralgia, but to be of great value in the treatment 
of various ophthalmic disorders of which this symptom is a 
prominent feature, such as irido-cyclitis, choroiditis, chorio- 
retinitis, etc. 

Ruta. — Feeling of heat and sensation as of fire in the 
eyes, with soreness when reading by candle-light ; pressure on 
the upper wall of the orbits, with tearing pain in the eyeballs ; 
dimness of vision from exerting the eyes too much by reading 
or fine work. 



THERAPEUTIC INDICATIONS. 2%J 

In asthenopic symptoms arising from over-exertion of 
the eyes. 

Santonine. — Dimness and loss of vision ; giddiness ; 
troubled sight, with dilatation of the pupils ; convulsive 
twitchings of the eyes and lids. 

This remedy is reported to have been successful in a con- 
siderable number of cases of asthenopia, amaurosis, and 
cataract (?). 

Senega. — Swelling, burning and pressure of the eyelids, 
with burning pain in the margins ; eyelashes in the morning 
full of hard mucus ; illusions of sight ; extreme sensitiveness 
of the eyes to light. 

Senega appears to act very beneficially in blepharitis and 
conjunctivitis, attended with the above symptoms ; and is said, 
also, to have promoted absorption of hypopya, and of less 
fragments after cataract operations. 

Staphysagria. — Itchings of the margins of the eyelids ; 
pimples around the inflamed eye ; sticking shocks in the eye- 
ball, as if it would burst ; illusions of sight ; dilation of the 
pupils; aching and pressure in the eye; lachrymation and 
photophobia. 

This is an old and well-known remedy for blepharitis, 
styes, and small tarsal tumors ; and it is also reported to have 
cured several cases of the so-called "arthritic ophthalmia." 

Sticta. — Burning in the eyelids, with soreness of the ball 
in closing the lids, or turning the eyes. 

In catarrhal conjunctivitis, with profuse but mild discharge. 

Zinc phos. — Retinal hyperemia ; extreme sensitiveness of 
the eyes to light ; photopsia, photophobia, and chromopsia. 

In hyperesthesia and hyperemia of the retina. 



288 PRACTICE OF MEDICINE. 



TABLE A. 

OPHTHALMIC SYMPTOMS. 

i. Agglutination— Bell., Calc, Care, v., Caus., Euphorb., 
Hep., Kali, Lyc, Nat. m., Nux v., Phos., Puls., Rhus., Ruta, Sep., 
Silic, Staph., Bry., Ign., Stann., Alum., Croc, Nit. ac, Plumb., 
Sulph., Thuja. 

2. Burning — Ars., Arn., Bell., Bry., Calc, Con., Cham., 
Croc, Dig., Rhod., Ruta, Spig., Spong., Thuja., Alum., Canth., 
Ferr., Graph., Ign., Kali, Nit. ac, Plumb., Puis., Rhus. Sep., Staph., 
Sulph., Aeon., Agar., Aur., Bar., Chin., Dros., Hell., Lyc, Mur. ac, 
Nux v., Phos., Silic, Strain. 

3. Dryness — Bry., Staph., Sulph., Ver at., Bell., Puis., Agar., 
Bar., Caust., Croc, Euph., Kali, Lyc, Nat. m., Nux v., Phos., Spig. 

4. Lachrymation — Acon., Arn., Bell., Bry., Calc, Caust., 
Chin., Coloc, Digit., Euph., Ferr., Graph., Hep., Ign., Kali a, 
Lyc, Merc, Nat. m., Nux v., Phos., Puls , Rhus, Ruta, Spig., 
Spong., Stram., Sulph., Verat. a. Alum., Ars., Bar., Chelid., Con., 
Croc, Rhodod., Seneg., Sep., Sil., Stan., Staph., Zinc, Agar., Camph., 
Canth., Carb. v., Cina, Coff., Hell., Lach., Op., Petr., Ph. ac, Plat. 

5. Neuralgia — Atrop., Bell., Cedr., Cham., Prunus sp., 
Spig., Chin., Cinnab., Sil., Asafcet., Bry., Cimicif., Crotal., Ign., Mez., 
Nat. m., Plat., Sulph., Thuj. 

6. Pupils, Dilated — Acon., Bell., Calc, Chin., Cina, Croc, 
Hep., Hyosc, Ign., Ipec, Sec c, Spig., Stram., Verat., Zinc. 
Agar., Am., Hell, Nux v., Ph. ac, Puis., Ars., Aur., Caust., Con., 
Cupr., Dig., Mur. ac, Nit. ac, Petr., Plumb., Stann. 

Pupils, Contracted — Arn., Camph., Cham., Chin., Cic, Hyosc, 
Ign., Puls., Sulph., Verat., Aeon., Agar., Ars., Aur., Bell., Cina, 
Cocc, Dros., Plumb., Sec c, St) am., Calc, Canth., Digt., Hell., Mur. 
ac, Ph. ac, Stann., Thuj. 

7. Redness, Inflammatory. — Acon., Apis, Arn., Ars., Bell., 
Bry., Calc, Cham., Chin., Digt., Euphr., Ign., Merc, Nat. m., Nit. 
ac, Nux v., Phos., Ph. ac, Puls., Rhus, Sep., Silic, Spig., Sulph., 
Verat., Coloc, Cupr., Euphorb., Ipec, Kali, Lyc, Staph., Bar., 



OPHTHALMIC SYMPTOMS. 289 

Camph., Canth., Carb. v., Con., Dulc, Ferr., Graph., Hep., Hyosc, 
Op., Plumb. 

8. Smarting— Agar., Con., Merc, Nux v., Rhus,Val., Alum., 
Canth., Chin., Graph., Sep., Staph., Ars., Bell., Bry., Calc, Carb. v., 
Caust., Croc., Dros., Euphor., Hell., Hep., Kali, Lye, Mur. ac, 
Nit. ac, Phos., Ph. ac. Sulph., Thuj. 

9. Swelling— Ars., Rhus, Stram., Bry., Carb. v., Hep., Nux, v. 
Phos., Plumb., Ruta, Sulph. 

10. Ulceration, Tarsal— Spong., Sulph., Am., Calc, Cham., 
Lyc, Phos., SiL, Staph., Alum., Bar., Caust., Kali, Nit. ac, Sep. 

11. Ulceration, Corneal. — Arg. n., Ars., Aur., Calc, 
Graph., Hepar., Kali bic, Merc, Aeon., Canth., Cinnab., Nat. m., 
Silic., Sulph., Apis, Arn., Cham., Chin., Cimicit., Con., Crot. tig., 
Ham., Puis.. Rhus. 

12. Vision, A. — Amblyopia: Bell., Phos., Zinc, Gels., Merc, 
Sant., Aeon., Alum., Arn., Ars., Aur., Bar., Bov., Calc, Chel., Chin., 
Crot., Cyclam., Ign., Kali, Lye, Nat. m., Puis., Ruta., Sep., SiL, 
Sulph., Thuj. 

B. — Chromopsia. — Bell., Con., Croc, Digit., Kali, Alum., 
Ars., Calc, Cann., Canth., Hep., Hyos., Merc, Ph. ac, Phos., Sep., 
Spig., Stram., Zinc. 

C. — Diplopia. — Bell., Digit, Euphorb., Hyosc, Puls., Sec. c, 
Sulph., Verat., Aur., Cic, Stram., Agar., Graph., Nit. ac, Merc, 
Petr. 

D. — Hemiopia. — Aur., Lith. c, Lyc, Mur. ac, Nat. m., Sep., 
Bov., Cyclam., Digt., Calc, Chin., Lob., Viola od. 

E. — Hemeralopia. — Hyos., Ranun., Verat., Arg. nit., Digt., 
Sulph., Bell., Chin., Lyc, Merc, Puis., Stram. 

F. — Photophobia. — A con., Arn., Ars., Bell., Bry., Cham., 
Chin., Con., Euphr., Graph., Hep., Ign., Merc, Nux v., Puls., 
Sep., Sulph., Cic, Cin., Croc, Sant., Alum., Camph., Coff., Hell., 
Kali, Lyc, Mur. ac, Nit. ac, Ph. ac, Sil. 

G. — Pholopsia. — Bell., Bry., Spig., Bar., Caust., Kali, Sil, 
Verat., Ars., Aur., Calc, Coloc, Croc, Digt., Dulc, Nat. m. Nux v., 
Op., Petr., Ph. ac, Staph., Stram. 

H. — Vitreous Opacities. — Kali iod., Sil., Sulph., Calc, Nat. 
m. Nit. ac, Phos., Sep., Arn., Bell., Carb. v., Caust., Ham., Kal., 
Lach., Lyc, Merc, Petr., Prunus, Sol. n. 



29O PRACTICE OF MEDICINE. 

TABLE B. 

OPHTHALMIC INFLAMMATION. 

i. Conjunctivitis — Apis, Arg. nit., Bell., Euphr., Merc, 
Puls., Rhus, Sep.. Sulph., Am., Ars., Calc, Cham., Cinnab., Graph. , 
Hepar., Ign., Nux. v., Sang., Spig., Zinc, Alum , Chelid., Croc, Cupr., 
Euphor., Kali bic, Nat. m., Sen., Thuj. 

2. Blepharitis — Acon., Alum., Apis, Arg. nit., Ars., Calc, 
Caust., Cinnab. . Euphr., Graph., Hepar, Merc, Nat. m., Petr., 
Puls., Sep., Silic, Aur., Cham., Crot. fig, Merc, Nux v., Psor., Rhus, 
Staph., Tellur., Bell., Clem., Colch., Kali, Lye, Phos. ac, Sang., 
Seneg., Viola trie. 

3. Keratitis — Acon., Apls, Arg. nit., Arn., Ars.. Aur., Calc, 
Canth.. Cham., Chin., Cimicif., Con..tCrot. tig., Euphr., Graph., 
Ham., Hepar., Kali bic, Merc, Nat. m.. Nux v. Puls., Rhus, 
Sec c, Sil., Sulph., Aur. m., Bar., Sep., Thuj., Vaccin., Alum., 
Bell., Caust., Chin., Kreos., Nit. ac, Seneg. 

4. Episcleritis. — Acon., Kal., Merc, Silic, Thuj., Puis., 
Cocc. , Spig., Sulph. 

5. Iritis. — Acon., Arn., Ars., Aur.. Bell., Bry., Calend., 
Cedr., Chin., Clem., Con., Euphr., Gels., Ham., Hepar., Kali iod., 
Merc, Nit. ac, Nux v., Petr., Rhus, Silic, Spig., Sulph., 
Terebinth., Thuj. Arg. nit., Asafcet., Cinnab., Nat. m., Puis., Cocc, 
Crot. tig., Hyos., Led., Plumb., Stilling., Zinc. 

6. Cyclitis — Kali iod., Merc, Bell., Bry., Rhus, Silic. 3 Apis., 
Ars., Aur., Prunus sp., Thuj. 

7. Choroiditis — Aur., Bell., Bry., Gels., Kali iod., Merc, 
Nux v., Phos., Prunus sp., Puls., Sulph., Apis, Ars., Hepr., Phyt., 
Rhus t., Acon., Coloc , Ipec, Psor., Ruta, Sil., Sol. nig. 

8. Glaucoma. — Bell., Bry., Cedr., Coloc, Phos., Pru. sp., 
Rhododen., Spig., Kali iod., Merc, Phyto., Arn., Ars., Aur., Cham., 
Cocc, Collin., Con., Crot. tig., Gels, Ham.. Nux v., Sulph. 

9. Retinitis — Bell., Bry., Cact., Con., Merc, Nux v., Phos., 
Puls., Apis, Asafcet., Ars., Aur., Gels., Kalm., Kali iod., Aeon., 
Collin., Croc, Lach., Leptan., Spig., Sulph., Zinc. 

10. Orbital Cellulitis. — Acon., Apis, Hepar., Lach., Merc, 
Rhus., Calc, Kali iod., Caust., Sil., Sulph. 

11. Dacryocystitis — Acon., Hepar, Merc, Puls., SiL.,Arumt., 
Arg. nit., Euphr., Petr., Cinnab., Hydras., Nat. m., Sang., Stilling., 
Sulph. 

12. Fistula Lachrymalis — Arg. nit., Brom., Fluor, ac, 
Calc, Lach., Petr., Nat. m., Silic, Sulph. 



SYMBLEPHARON. 2CjI 

DIV. II. 

RESULTS OF OPHTHALMIC INFLAMMATION. 

Many of the consequences of ophthalmic inflammation have 
already received the attention at our hand which their rela- 
tive importance, and the general object we have had in view, 
has seemed to demand. Others, however, have been but 
briefly noticed, or only incidentally referred to, and will there- 
fore require to be separately considered. But as we have 
already devoted as much space to the subject of inflammation 
as we can well spare for that purpose, we shall aim in what 
follows to be as brief and practical as possible. 

1.-SYMBLEPHAE0N. 

This term denotes a more or less extensive adhesion of 
the mucous membrane of the lids to that of the globe. The 
adhesions may be direct and close, so as to cause very great 
limitation of the movements of the ball ; or they may consist 
of narrow bridges of connection, either slender and chord-like, 
or thin and membranous. These loose attachments are 
supposed to be formed by the movements of the globe, and 
consequent stretching of the original adhesions. The affection 
may be produced by any cause which gives rise to ulceration of 
the two opposed conjunctival surfaces, whether it be the acci- 
dental introduction of caustic substances, such as lime or 
mortar, between the lids, or the destruction of the superficial 
epithelial layers by the knife or caustic, as in careless oper- 
ations for the removal of trachoma, pterygium, etc. 

Treatment. — When the adhesions are extensive, it is 
almost impossible to prevent their ultimate reunion after sep- 
aration. Surgeons of the highest eminence have recorded 
their repeated attempts and failures in this direction. The 
difficulty seems to lie in the contraction of the new formations, 



292 PRACTICE OF MEDICINE. 

and the consequent difficulty of permanently separating the 
granulating surfaces. Almost every form of mechanical contri- 
vance has been made use of to prevent the junction of the raw 
surfaces ; and for this purpose shields of metal, glass, ivory, 
and other substances, have been interposed between the lids 
and globe ; but as contraction takes place during the process of 
cicatrization, the interposed substance is gradually pushed out, 
and although the case may seem to do well at first, the operation 
is almost certain, in the end, to prove a failure. Probably Mr. 
Wordsworth's glass shell, mentioned by Wells, which has a 
central opening for the cornea, and resembles an aitificial eye, 
would, as the inventor claims, be successful in many cases, 
provided it were worn continuously for a sufficient length of 
time ; for it should be remembered that, as in the case of 
burns, the new formation is imperfectly organized and liable to 
absorption, and consequently, as pointed out by Walton, con- 
traction continues for some time after the completion of the 
cicatrix. 

Of the many operative procedures that have been devised 
for symblepharon, the following appear to be the most reliable, 
and may be adopted in moderate cases with reasonable pros- 
pect of success : 

1. That of Amussat, which consists in freely dividing all 
existing adhesions, and then daily carrying the point of a 
probe, or of a cutting instrument, to the extremity of the 
division ; this is continued until the pyogenic surfaces are cica- 
trized, and can no longer grow together. 

2. Petrequin's ligature process, which consists in carrying 
a double ligature through the adhesion, one portion of which is 
tied with great firmness close to the sclerotica, and the other 
with a less degree of compression near the lid. As the former 
sloughs away at an earlier period than the latter, the part near 
the eyeball heals before the other, and the cicatrization be- 
comes too far advanced to admit of its reattachment to the 
outer part. 



ANCHYLOBLEPHARON. 293 

3. Arlt's process, which consists in first passing two liga- 
tures through the symblepharon close to the cornea, and after 
carefully dividing the adhesions as far back as the retro-tarsal 
fold, doubling down the symblepharon so as to bring its con- 
junctival surface in apposition with the raw surface of the 
globe, and then passing the ligatures through the lid close to 
the orbital border, tying them on the outside. After the orbi- 
tal wound has healed, if the shrunken remains of the symble- 
pharon prove troublesome to the patient, they may be safely 
snipped off with a pair of scissors. 

4. Teale's method by transplantation. This consists in 
first separating the adhesions in the usual manner, beginning at 
the margin of the cornea, and then interposing one or more flaps 
of conjunctiva previously dissected from neighboring portions 
of the globe. The flaps are adjusted in their new positions by 
means of fine silk ligatures, "and their vitality is further pro- 
vided for by incising the conjunctiva near their base, in any 
direction in which there seems to be undue tension." He also 
stitches together the margins of the gap from which the trans- 
planted conjunctiva has been removed. In adjusting the flaps, 
great care should be taken to prevent the doubling in of their 
edges, which would be likely to prevent the full success of the 
operation. 

2 -ANCHYLOBLEPHARON. 

This term denotes a firm adhesion of the two lids, which 
may be either complete or partial, congenital or acquired. In 
the majority of cases the adhesion is partial, and is usually 
limited to the outer angle. The union is generally of a mem- 
branous nature, especially in congenital cases ; but when com- 
plicated with symblepharon, or when caused by severe mechan- 
ical or chemical injuries, it is apt to be thick and tendinous. 

Treatment. — If the adhesion is membranous, or if it is 



294 PRACTICE OF MEDICINE. 

limited to one or more points, the lids should be carefully 
separated upon a director, and readhesion prevented by care- 
fully drying the edges, and then touching the raw surfaces with 
collodion, as first suggested by Walton ; but if the union is 
large and broad, and especially if it is confined to the palpebral 
angle, the most appropriate and effective treatment is the oper- 
ation of Canthoplasty, (which see). 

3.-BNTR0PIUM. 

By entropium is meant a more or less extensive inversion 
of the lids. It is usually complicated with trichiasis, or turning 
in of the cilia, which is generally regarded as constituting the 
first degree of entropium. We recognize two principal forms 
of the affection ; the spasmodic, which usually occurs in 
elderly people, and hence is frequently called senile entropium; 
and the chronic, which is generally due to inflammatory and 
structural changes in the conjunctiva and tarsal cartilages. 
The former, which is frequently temporary, is generally met 
with in the lower lid, but it may also occur in the upper. The 
affection is often accompanied with great irritation from the 
friction of the cilia against the globe, which frequently gives 
rise to inflammation, and leads sooner or later to ulceration 
and opacity of the cornea. 

Treatment. — The most simple and effective treatment 
for spasmodic entropium, particularly in senile cases, is the 
operation of canthoplasty, care being taken to make the incision 
oblique instead of horizontal, so as to relax the orbicularis 
muscle to the fullest extent. Generally, the incision should 
be in a downward direction, because it is usually the lower lid 
that is affected. If this fails to keep the lid in its natural 
position, its external surface should be painted with collodion, 
the contraction of which in drying is sometimes sufficient, 
even without the operation, to prevent the lid from again 
becoming inverted. 



entropium. 295 

When the central part of the lid is greatly relaxed, as it 
usually is in old cases, some surgeons, in order to equalize the 
tension, instead of extending the edge of the lid, as above 
recommended, remove a triangular piece of integument from 
the central, or most relaxed portion. An incision is first made 
about one and a half lines from the free border of the lid, and 
parallel with it, extending on either side to within one or two 
lines of the commissure. Two oblique incisions are then 
made from points about midway between the centre and the 
two extremities of the horizontal incision, converging towards 
the orbital border, so as to include a triangular portion of the 
integument, which is dissected up and removed. The sides of 
the wound are then united by two or three fine sutures, the 
horizontal incision being left to itself. When healed, the 
cicatrix will be in the form of the letter T. In very bad 
cases, especially where there is a narrowing of the palpebral 
fissure, it is best to combine this operation with that of can- 
thoplasty, above described. 

In case there is much contraction and incurvation of the 
tarsal cartilage, it may also be found necessary to remove a 
portion of the latter, which is best done by turning back the 
upper angles of the V-shaped incision in the operation just 
described, as far as the ends of the horizontal incision, and then 
cutting out a wedge-shaped portion of the cartilage, by mak- 
ing two nearly parallel incisions into it along the palpebral 
margin nearly down to its inner surface, at the same time 
sloping them towards each other so as to meet near its posterior 
surface. The strip to be removed is then seized with a pair 
of forceps, and detached with a few touches of the scalpel. 
The extent to which this "grooving process" should be carried, 
will depend, of course, upon the degree of contraction and 
dislocation of the cartilage. 

If these operative procedures fail to rectify the position 
of the lids, there remains no other resource than to remove the 
hair-follicles, as described under Trichiasis, (which see). 



2g6 PRACTICE OF MEDICINE. 

4.-ECTR0PIUM. 

Ectropium is the reverse of entropium ; that is, it is a 
turning out of the eyelid, so that more or less of its conjunc- 
tival surface is exposed. It is generally confined to the lower 
lid, though it may affect both. There are various degrees of 
the affection, ranging from a slight eversion of the border of 
the lid, to one in which the entire surfaces are reversed. Of 
course this malposition of the lids interferes with the proper 
discharge of the tears, so that the eye is always more or less 
suffused and watery ; and in severe cases, especially of the 
lower lid, they frequently pour over the side of the cheek, 
inflaming and excoriating the latter, and even increasing the 
ectropium, by causing contraction of the integuments. In 
fact, it is this contraction of the skin near the edges of the 
lids, during cicatrization from long-continued excoriation, 
burns, wounds, etc., that most frequently gives rise to ectro- 
pium. But severe forms of conjunctivitis, especially the 
purulent and granular, also produce it, in consequence of the 
extensive swelling and hypertrophy of the conjunctiva, the 
eversion being aided by the action of the orbicularis. Other 
causes are : paralysis of the portio dura, chronic blepharitis, 
or lippitudo, abscess of the lids, abscess and caries of the 
orbit, especially of its margin, intra-orbital tumors, cancerous 
growths, and exophthalmos. 

Treatment. — If the cause of the displacement can be 
removed, acute and recent cases will, as a general rule, require 
no additional treatment, except the simple replacement of the 
lid, and its retention in the normal position by a compress 
bandage. But when the eversion is of long-standing, the tar- 
sus becomes more or less elongated, so that the lid will no 
longer fit the globe, even after it is restored to its natural 
position. It then becomes necessary to narrow the palpebral 



ECTROPIUM. 297 

fissure by the operation of tarsoraphia. This operation, devised 

by Walther, may be performed as follows : — The operator 

ascertains the extent of the surplus tissues, by first reducing 

the dislocated lid, and then, having put its border slightly on 

the stretch, pinches up the loose tissues at the outer canthus, 

until the margins of the two lids fit each other, marking with 

ink the boundaries thus included. He then inserts a horn or 

ivory spatula between this portion of the lids, and, beginning 

at the outer canthus, makes a crescent-shaped incision along 

the previously-marked boundary, through the skin and cellular 

tissue, to the point where the two lids should meet. He then 

shaves off this portion of the lids, including its cilia, as far 

back as the outer canthus, being careful not to leave any of 

the hair follicles behind, as these would grow again. The two 

raw surfaces are then brought together, and secured by three 

or four interrupted sutures. In order to lessen the strain upon 

the sutures, adhesive strips may be applied in such a manner 

as to draw the integuments towards the junction of the lids, 

which should be that of a straight horizontal line. When 

there is a marked difference in the length of the tarsal edges, 

it is generally necessary before completing the operation, in 

order to prevent a bulging of the fascia and cartilage, under 

the sutures, to excise a portion of the latter, in shape like an 

Italic V ; the edges of the incision should then be included in 

the suture. 

For ectropium resulting from cicatrices near the margin of 

the lids, and causing their eversion by traction, a great variety 

of operations has been devised, most of which are simple 

modifications of the following, which is known as DiefTen- 

bach's :— The cicatrix, or so much of it as may be necessary, 

is removed by a triangular-shaped incision, the base of which 

is turned towards the ciliary margin, and the apex to the 

cheek. The incision which forms the base of the triangle, is 

then extended on each side at right angles to the sides of the 

former triangle, and the flaps thus formed are raised a little 
38 



298 PRACTICE OF MEDICINE. 

from the subjacent parts, brought together so as to fill the 
triangular space previously occupied by the cicatrix, and the T- 
shaped wound thus formed united by fine sutures. In case the 
ciliary margin remains too much relaxed, tarsoraphia may be 
advantageously united with this operation. 

For such exceptional cases of ectropium and lagophthal- 
mos as will not admit of being successfully treated by the 
above operations, the reader is referred to the larger works on 
ophthalmology, particularly those of Wells and Stellwag, 
where he will find a great variety of blepheroplastic operations 
fully illustrated and described. 

5.-TRICHIASIS. 

This is a disease in which the eyelashes are inverted, or 
turned inward toward the globe. The malposition may affect 
the whole or only a portion of the cilia, which are always more 
or less degenerated and distorted. Supernumery cilia are 
not uncommmon in these cases, as many as four or five having 
been found to spring from the same hair-follicle. These gen- 
erally have the appearence of new hairs, being for the most 
part short, fine and colorless. In some cases the cilia appear 
to be arranged in two distinct rows, and then the disease is 
called distichiasis. The misplaced cilia are generally turned 
inwards, and by constantly sweeping against the globe excite 
considerable irritation, which is accompanied, in some cases, 
by severe lachrymation and photophobia. If the abnormal 
friction is allowed to continue, vascular keratitis sets in, and 
this is followed by pannus. It may also cause severe spasm 
of the lids, which in turn may give rise to some degree of 
ectropium. 

ETIOLOGY. — The most frequent causes of trichiasis are 
those which give rise to structural changes in the edges of the 
lids, such as blepharitis ciliaris, purulent and granular ophthal- 
mia, cicatricial contractions, etc. 

Treatment. — This is either palliative or radical. The 



TRICHIASIS. 299 

palliative treatment consists in removing the misdirected cilia, 
as fast as they grow, with forceps. If this treatment is con- 
tinued for a sufficient length of time, it may finally result in 
atrophy of the hair-follicles, and thus prove radical ; but as a 
general rule the cilia continue to grow, and require to be ex- 
tracted as often as they are reproduced. The radical treatment 
consists in either giving to the cilia a more natural and harm- 
less direction, or else in extirpating the bulbs of the inverted 
lashes. The latter is generally the most successful method ; 
but the loss of the cilia is so disfiguring to the patient, 
especially in the upper lid, that the operation should, if possi- 
ble, be avoided. Sometimes we can succeed in turning the 
cilia away from the globe, by merely pinching up a fold of the 
integument near the ciliary border, and excising it. When 
this will answer the purpose, it is the best plan to adopt, as it 
not only preserves the cilia, but the success of the operation is 
confirmed by the subsequent contraction, and the subsidence of 
the irritation and swelling. If this fails to meet the indication, 
we may frequently succeed by first making perpendicular incis- 
ions down to the cartilage at the extremities of the trichiasis, 
and then uniting them at the ciliary margin by carrying an in- 
cision along the edge of the lid, between the meibomian ducts 
and cilia ; after which sufficient of the integuments should be 
excised to evert the cilia, and with them any coexisting entro- 
pium. If this procedure, which is a modification of Von 
Graefe's operation, will not suffice, then the best method, not- 
withstanding the resulting deformity, is to remove the hair 
bulbs. This operation is both tedious and painful, especially 
when a considerable number of the cilia are misplaced, and 
therefore it is better to perform it when the patient is under the 
influence of chloroform. A horn or any other suitable spatula is 
first placed under the lid, and is held there by an assistant, 
who at the same time raises the lid from the globe, and causes 
its edge to be somewhat everted. Then the edge of the lid 
is split, or divided into two layers, to the depth of about two 



300 PRACTICE OF MEDICINE. 

lines, with a scalpel or other suitable knife, (PI. I, Fig. 22), 
being careful not to continue the incision into the lachrymal 
puncta. The incision should be made close to the surface of 
the cartilage, so that all the hair-follicles may be included in 
the anterior layer. The integument is then divided behind the 
hair-bulbs, by a horizontal incision extending down to the 
fascia, which, if the trichiasis involves the whole of the lashes, 
should meet the free border of the lid at an obtuse angle, two 
lines beyond the commissure. The portion thus included may 
then be liberated with a few touches of the scalpel ; and if any 
of the hair-bulbs still remain, they should be carefully excised, 
otherwise some of the cilia will be reproduced. Sutures are 
not required, but a wet compress should be applied, and in a 
few days the wound will be healed. Should there have been 
any coexisting entropium, or rolling in of the edge of the 
lid, it will be corrected by contraction of the cicatrix. 

6.-XEE0PHTHALMIA. 

This affection, sometimes called xerosis conjunctivae, con- 
sists in a dry or cuticular state of the conjunctiva, which loses its 
character of a mucous membrane, and no longer secretes. 
The surface of the membrane becomes rough, scaly, and of a 
greyish-white color, being sometimes finely granulated, at 
others resembling cicatricial tissue. The opposed surfaces are 
so dry, rough and stiff, as greatly to hinder the movements of 
both the eye and lids ; and this is still farther increased by 
contraction of the conjuctiva, and by a greater or less accum- 
ulation of hardened epitheliel scales within the narrowed 
conjunctival sac. In the great majority of cases, also, there 
is partial symblepharon, the lids adhering to each other and to 
the caruncula ; the puncta are frequently obliterated ; and the 
upper lid is sometimes so much shortened, that the eye cannot 
be shut, producing the state of lagophthalmus. When the 
globe or lids are moved, the ocular conjunctiva is thrown into 
folds round the cornea. No moisture is perceived on rubbing 



PTERYGIUM. 301 

the cornea, the surface of which is generally rough, uneven, 
and greatly deficient in sensibility. The cornea is generally 
obscure, the opacity being so great, in some cases, that the 
color of the iris and the state of the pupil cannot be recog- 
nized. Not only the cornea, but also the conjunctiva, becomes 
anaesthetic, dust and dirt accumulating between the lids, and 
exciting little or no irritation. 

Etiology. — This incurable affection is generally caused 
by chronic granular conjunctivitis ; and is most apt to result 
from neglected or badly treated cases, especially when deep 
scarification and too severe caustics are employed. It also 
follows diphtheritic conjunctivitis, especially when the latter is 
attended with sloughing. Symblepharon accompanied with 
severe inflammation, trichiasis, entropium, logophthalmos, and 
injuries resulting from burns, strong acids, etc., are among the 
less frequent, but occasional causes. 

Treatment. — This is merely palliative, the best we can do 
being to mitigate, or temporarily relieve the dryness of the 
conjunctiva, by the frequent use of some bland fluid, such as a 
weak solution of glycerine, milk, artificial serum, etc. These 
collyria act beneficially by washing away the hardened epithe- 
lium from the surface of the cornea, and thus render the latter 
more transparent. 

7.-PTERYGIUM. 

This term, which is derived from a Greek word signifying 
a wing y is used to denote an hypertrophied condition of the 
conjunctival and episcleral tissues. It is usually situated at 
the inner canthus, and is of a triangular form, the base at the 
semilunar fold, and the apex near the margin of the cornea, 
towards the centre of which it gradually advances. It presents 
more or less of a tendinous or fibrous structure, and is traversed 
in the direction of its length by numerous nearly parallel 
bloodvessels. It is divided into two principal forms, according 
to the greater or less degree of hypertrophy exhibited at 



302 PRACTICE OF MEDICINE. 

different periods of its growth. While thin, transparent and 
delicate, it is called pterygium tenue or membranaceum, but 
when it becomes thick and fleshy, it is termed pterygium 
crassum or carnosum. It is generally somewhat loosely con- 
nected with the subjacent parts, so that it can be easily raised 
with the forceps ; but if the conjunctival portion contains any 
considerable amount of ligamentous or tendinous tissue in its 
structure, it is thereby rendered less yielding, and may even 
impede to some extent the movements of the globe. 

Pterygium usually occurs about the middle period of life, 
and makes its appearance quite insensibly, the disease 
frequently making considerable progress before the patient is 
aware of its existence. 

Its growth is generally very slow, the pterygium advancing 
gradually to the margin of the cornea, where its progress is 
sometimes arrested ; in other cases it extends more or less on 
to the cornea, but it seldom passes beyond the centre. The 
corneal portion is less vascular and more compact and tendin- 
ous than the conjunctival, especially the extreme point of the 
pterygium, which not unfrequently appears round and bead-like. 

Etiology. — The chief cause of pterygium appears to be 
some injury which irritates the ocular conjunctiva, such as may 
result from prolonged exposure to wind, dust, heat, etc. 
Hence its usual seat at the internal canthus, where the con- 
junctiva is most exposed to the operation of such agencies. 
Hence, also, its frequent occurrence among the inhabitants of 
hot climates, and among sea captains, stone-cutters, masons, 
etc. Pterygium may also result from phlyctenular keratitis, 
superficial ulceration of the margin of the cornea, or any other 
cause capable of giving rise to inflammatory hypertrophy of 
the conjunctival and episcleral tissue. 

Treatment. — If the pterygium is small, or thin and 
vascular, it may yield to Arg. nit., Ars., Calc, Chin., Lach., 
Nux mos., Psor., Ratan., Spig., Sulph., or Zinc, all of which 
have proved beneficial in particular cases. But if the occupa- 



PTERYGIUM. 303 

tion or habits of the patient are such as to favor its growth, it 
will be necessary to abandon them before any internal treat- 
ment will be likely to prove successful. If symptoms of 
severe irritation exist, they should be allayed by appropriate 
treatment ; and for this purpose much good sometimes results 
from the use of mild astringent collyria, especially if there is 
any catarrhal or other form of ophthalmia connected with it. 

But if the pterygium is large and thick, and especially if 
it is composed of true connective tissue, these means are 
insufficient, and we can only remove it by resorting to opera- 
tive procedures. But since these are not always perfectly 
successful — the cicatrix or some portion of hypertrophied 
tissue remaining, which may even necessitate a further opera- 
tion — so long as the pterygium does not interfere, nor seem 
likely to interfere, with vision, or with a free and unrestricted 
movement of the globe, it should not be operated upon. On 
the other hand, if the morbid growth has so far encroached on 
the cornea as to impede vision, or if it should threaten to do 
so, and especially if its size and character are such as to limit 
to any considerable degree the movement of the globe, we 
should remove the pterygium by one of the following methods: 

(1). Excision. — The patient having been brought under 
the influence of an anaesthetic, the lids separated by the 
stop-speculum (PL II, Fig, 33), and the globe turned slightly 
in the direction of the pterygium, and there held by a^suitable 
instrument, (PI. I, Fig, 16), the operator seizes the growth with 
a pair of reliable forceps, and raises it sufficiently to pass a 
pointed narrow-bladed knife (Fig. 13) under it, with which he 
first excises the corneal, and then the scleral portion, dissecting 
the latter toward the palpebral fold to a distance of one and 
a half or two lines from the margin of the cornea, thus far 
following exactly the edges of the pterygium, and keeping 
close to the surface of the cornea and sclerotica. From this 
point the dissection is continued toward the base of the 
pterygium, not by following the edges of the latter, as before, 



304 PRACTICE OF MEDICINE. 

which would form a triangular wound, but by two converging 
incisions, meeting in front of the reflection, so as to give the 
wound somewhat of a rhomboidal shape. Having removed all 
hypertrophied tissue, the edges of the wound should be closed by 
two or three fine sutures. A protective bandage should then be 
applied, and in three or four days the sutures may be removed. 

(2). Ligation. — The lids having been separated and the 
globe fixed as above described, the operator raises the ptery- 
gium with a pair of forceps, and passes a fine curved needle, 
armed with a double silk ligature, beneath it from border to 
border, first near the margin of the cornea, and afterwards at 
the base of the pterygium. The thread now forms a double 
loop on one side of the pterygium, by cutting one thread of 
which, the ligature, after the removal of the needle, is divided 
into three portions, an outer, middle, and inner one. The ends of 
the inner thread are first tied, then those of the outer, and 
finally the two ends of the middle one, which are both on the 
same side of the pterygium. At the expiration of four or five 
days, the ligated portion of the pterygium may be easily 
detached with the forceps. 

(3). Transplantation. — This operation, which was first 
introduced by Desmarres, and afterwards greatly improved by 
Knapp, is now generally performed in the following manner : — 
The corneal portion of the pterygium is first dissected off, and 
excised. Two curved incisions are then made in the direction 
of the retro-tarsal folds, from the upper and lower borders of 
the base of the pterygium. The latter is next divided into 
two equal portions by a horizontal incision extending to its 
base. After this, two small conjunctival flaps are formed, one 
on either side of the wound, for the purpose of covering it. 
The contraction of the flaps causes the two curved incisions to 
gape sufficiently to receive the corresponding halves of the 
pterygium, where they are secured by fine sutures. Finally, 
the conjunctival flaps are brought together over the former 
seat of the pterygium, and there united. 



DISEASES OF THE EYE. 305 

8.-0PACITIES OF THE COENEA. 

Under the head of Keratitis will be found a general 
description of the nature, situation, and extent of the various 
forms of corneal opacity. They may be summarized as 
follows : 

(1). Epithelial or Nebulous Opacities. — These are thin and 
superficial, appearing like a mist or cloud upon the surface of 
the cornea. They are sometimes so fine as to be extremely 
difficult of detection, unless the cornea is examined with a 
convex lens or by lateral illumination. 

(2.) Parenchymatous Opacities. — These thicker and 
deeper-seated forms of opacity are named, from their color, 
leucoma. When "complete," the entire cornea has a whitish or 
bluish-white appearance, very much resembling the sclera, the 
surface frequently retaining its normal lustre. When "partial," 
the opacity is more or less cloud-like, the border being irregular, 
and gradually shaded off into the unaffected portions of the 
cornea. The color varies from a greyish or bluish transparency 
to a yellowish, or even chalky-white tint. 

(3). Tendinous or Cicatricial Opacities. — These are more 
or less superficial, according to the depth of the original ulcer. 
They generally have a tendinous or glistening-white appear- 
ance, especially the central portions. The edges are frequently 
indistinct, owing to their being surrounded by an epithelial 
cloudiness, the result of recent inflammatory changes, which 
in the course of time becomes absorbed. 

(4). Calcareous Opacities. — These opacities, consisting of 
the carbonate and phosphate of lime, are of a brownish tint. 
They are situated just under the epithelium, and have an 
irregular and somewhat indistinct outline, shading off more or 
less gradually into the normal transparent cornea. 

PROGNOSIS. — This depends chiefly upon the duration, 
nature, and extent of the opacity. When recent, and especially 



306 PRACTICE OF MEDICINE. 

when occurring in young and vigorous patients, they almost 
always disappear sooner or later without treatment. Ten- 
dinous and cicatricial opacities never disappear altogether ; 
but at first they are generally surrounded by a cloudy border, 
which clears up in the course of time, the remaining opacity 
being lessened in extent, and its effect on vision greatly 
diminished. 

Treatment. — The cure of recent cases of corneal 
opacity is frequently hastened by the internal use of the 
following remedies. — Apis, Cannab., Chel., Crotal., Euph., 
Hep., Merc, Puis, n., Rhus and Sulph. Even old cases of 
leucoma are reported to have -been greatly benefited by the 
persistent administration of Ac. nit., Aur., Calc, Cup. al., 
Hep., Kali bic, Kali iod., Merc, Nat. sul., Sil., Spong., and 
Sulph. Of these, the following have also been employed 
externally : — Cup. al., Kali bic, Kali iod., Merc, and Nat. sul. 
There being no characteristic eye symptoms in these cases by 
which to make the selection, the indications will have to be 
sought for in other organs ; but if there is no derangement of 
the patient's health to guide us, we may, if all inflammatory 
symptoms have disappeared, endeavor to promote absorption 
by the cautious use of irritants, such as Merc, dulc, Nat. sul., 
etc, a small quantity of which may be daily dusted into the 
eye. Or we may make use of irritating collyria, beginning 
with weak solutions of the sulphate of zinc or copper, and 
either changing or gradually strengthening them as the eye 
becomes accustomed to their use. For this purpose we have 
generally found nothing better than a collyrium of Kali iod, 
(grs. ij — v ad § j). The action of these agents is often 
increased by the instillation of Atropine, which promotes 
absorption by diminishing the intra-ocular tension. Calcareous 
opacities should be carefully scraped off with a scalpel, as 
recommended by Dixon and Bowman. As this is a very 
painful operation, and denudes the cornea of epithelium, it 



STAPHYLOMA OF THE CORNEA. 30? 

should be done with the greatest care, and only a small 
quantity removed at a time ; a little olive or other bland oil 
being afterwards applied to the eye. 

In old and incurable cases, vision may sometimes be 
improved by diminishing the intensity of the diffused light by 
means of stenopaic spectacles. These are so constructed as 
to permit only the central rays to pass, thus cutting off the 
irregularly refracted rays from the periphery. These specta- 
cles, while they often answer very well for near objects, as in 
reading, writing, sewing, etc., are not adapted to general use, 
the field of vision being too much contracted to permit of 
freely moving about, as in walking, driving, etc. 

If these means fail of restoring serviceable vision, then our 
only resource is an artificial pupil, made behind a transparent 
part of the cornea ; selecting for this purpose the operation of 
iridectomy, iriodesis, iridoenkleisis, or corydialysis, according 
as one or the other may best suit the condition of the cornea 
and the optical principles involved in the case. See Operations 
for A rtificial Pupil. 

9.-STAPHYL0MA OF THE COENEA. 

There are three principal forms of corneal staphyloma, 
namely, (i), kerato-conus, or conical cornea; (2), kerato-globus, 
or buphthalmos ; and, (3), staphyloma of the cornea and iris. 
The first two forms are chiefly due to a weakening and thin- 
ning of the corneal tissue, and the last to ulceration and 
sloughing of the cornea, followed by prolapse and subsequent 
adhesion of the iris. 

A.— Conical Cornea. 

KERATO-CONUS. 

This form of staphyloma, if considerable, may be easily dis- 
tinguished by viewing the eye in profile, when the conical shape 



308 PRACTICE OF MEDICINE. 

of the cornea will be readily perceived. Slight cases, however, 
may be either entirely overlooked, or mistaken for amblyopic 
forms of myopia, unless we make an ophthalmoscopic examin- 
ation, when the smallest amount of conicity may be detected. 
In these examinations we use only the mirror, through which, 
if we view the cone exactly in the line of its axis, all the 
light will be reflected, and we shall see a bright red space, 
surrounded by a dark zone, and this again surrounded by 
another circle, which is red. If viewed obliquely, the part of 
the cone opposite to the light will be darkened. If we 
examine the interior of the eye, we can only see a small 
portion of the fundus ; while the retinal vessels and the border 
of the optic nerve entrance appear distorted and more or less 
indistinct. The slightest movement of the eye or mirror 
greatly increases the distortion, the irregular refraction through 
the cornea frequently giving a curled or twisted appearance to 
the vessels, and also to the border of the optic disc. 

Vision is always more or less impaired, and, in many 
cases, is insufficient to serve any useful purpose, the distortion 
and confusion of the retinal images being too great to admit 
of much improvement by any kind of stenopaic apparatus. 
Moreover, the apex of the cone seldom remains transparent, 
but sooner or later becomes hazy or opaque, and, in some cases, 
even tendinous or cicatricial. 

Etiology. — Inflammation is supposed to be one of the 
chief causes of kerato-conus ; but it cannot be the sole cause, 
as many cases occur in which no signs of inflammatory action 
ever appear. Neither is the bulging forward of the cornea due 
to intra-ocular pressure, for such eyes are almost always ab- 
normally soft. It appears to be due, rather, to a weakening 
and thinning of the cornea, the latter becoming more and 
more attenuated as the staphyloma increases. 

Prognosis. — The development of conical cornea is gen- 
erally very slow. It is often interrupted in its course, stop- 



STAPHYLOMA OF THE CORNEA. 309 

ping short at a certain point, then resting, perhaps, for years, 
and then increasing again without any apparent cause. Or it 
may cease at any stage of development and become perma- 
nently stationary. It is a singular circumstance in these cases 
that, however thin the apex of the cone may become, it never 
gives way unless it is accidentally ruptured. The disease is 
seldom monocular, but generally affects both eyes, either sim- 
ultaneously or in succession. 

Treatment. — It is highly probable that the progress of 
kerato-conus may, in some cases, be checked by the persistent 
use of proper homoeopathic remedies, even in cases in which 
there is no co-existing inflammation ; but, as yet, we are 
obliged to confess that we know of no internal remedy on 
which we can place reliance as a curative agent is these cases. 
It is true that Drs. Allen and Norton, in their work on ''Oph- 
thalmic Therapeutics," say that Calc. iod. has seemed to act 
favorably in their hands, and that "decided benefit has been 
obtained from its use in checking the progress of both conical 
cornea and staphyloma." The same remedy is even reported 
by H. Goullon to have cured a case of kerato-conus ; but this 
may well be taken cum grano salts, as we cannot conceive of 
the possibility of materially reducing the conicity of the cor- 
nea, except by incision, and this is generally very far from 
being a successful operation. Some diminution, however, may 
result from lessening the intra-ocular pressure by means of an 
iridectomy ; and, as we may in this manner possibly arrest the 
progress of the disease, and at the same time improve the 
vision, by making a pupil opposite the peripheral portion of 
the cornea, where it still retains, to a great degree, its normal 
curvature, it is the operation most frequently performed. The 
iridectomy should be of only moderate size, and, as suggested 
by Wells, should be made slightly upwards and inwards, so 
that a part of the base of the artificial pupil may be covered 
by the upper lid. When the conicity of the cornea is slight 



3IO PRACTICE OF MEDICINE. 

and almost stationary, some prefer an iridodesis to an iridec- 
tomy, with a view of displacing the pupil towards a portion of 
the cornea which is less abnormally curved, so as to lessen the 
diffusion and irregular refraction of the rays passing through 
it. Others, again, make an iridodesis on opposite sides of the 
pupil, so as to change the latter into a long, narrow slit, with a 
view to render the aperture stenopaic ; but the operation is 
said to offer no advantages over the ordinary method. 

B— Kerato-Qlobus. 

BUPHTHALMOS. 

In this disease the entire cornea, and generally the ante- 
rior portion of the sclerotica also, are bulged forward in such 
a manner as to give a uniform spherical curvature to the cor- 
nea, and a greater or less increase in the size of the whole an- 
terior portion of the eyeball. This increase is often so consio^ 
erable as to present an appearance similar to that of exoph- 
thalmos, the front portion of the globe protruding between the 
lids, and giving to the eye a peculiar staring expression, whence 
it has derived the name of buphtlvalmos . The effect of the 
enlargement is to increase the size of the anterior chamber in 
every direction. Hence the disease was for a long time re- 
garded as a dropsy of the anterior chamber {Jiydr ophthalmia 
anterior). The iris is stretched so as to be proportionally en- 
larged, the fibres appearing slightly separated, especially 
towards the ciliary margin. It is frequently somewhat cupped, 
particularly in a backward direction, and is occasionally tremu- 
lous, perhaps from losing the support of the lens, which is 
sometimes dislocated. The pupil is usually dilated and slug- 
gish, and more or less of its margin is sometimes adherent to 
the anterior capsule. The cornea may remain entirely trans- 
parent ; but, in most cases, it is more or less clouded, especially 



STAPHYLOMA OF THE CORNEA, 311 

on the periphery, and, in some instances, it is uniformly and 
densely opaque. As the disease progresses, glaucomatous 
symptoms supervene ; the tension increases, the optic disc 
becomes excavated, the lens is rendered opaque, the vitreous 
separates and becomes fluid, detachment of the retina occurs, 
and atrophy finally ensues ; or else, in consequence of the 
thinning of the anterior portion of the globe, the ball becomes 
ruptured. In either case, the disease is almost certain to ter- 
minate, sooner or later, in complete blindness. 

ETIOLOGY. — The etiology of this disease is somewhat 
obscure. It does not appear to be due to the increased intra- 
ocular pressure, since glaucomatous symptoms do not generally 
give rise to bulging of the cornea. Neither does it arise from 
an increased secretion of the aqueous humor. It must, there- 
fore, either originate in such an abnormal condition of the 
cornea as would constitute a predisposition to the disease, or 
else it must result from a weakening and thinning of the cor- 
neal tissue in consequence of some severe inflammation, such 
as vascular keratitis or pannus. The latter is probably the 
chief factor in its production in most cases. 

Treatment. — This is similar to the treatment recom- 
mended for Glaucoma (which see). 



C. —Staphyloma of the Cornea and Iris. 

This form of staphyloma is one whose walls are compos- 
ed, either wholly or in part, of cicatricial tissue, and is gener- 
ally the result of ulceration. Partial staphyloma is, in the 
majority of cases, only an advanced stage of what is called 
staphyloma tridis, or prolapse of the iris. As the latter usually 
occurs during the inflammatory process, the prolapsed iris soon 
becomes covered with lymph, which gradually assumes a cica- 
tricial character, and, being weaker or more extensible than 



312 PRACTICE OF MEDICINE. 

the normal cornea, readily yields to the intra-ocular pressure, 
and gives rise to "partial" staphyloma. The growth of the 
staphylomatous protrusion is generally slow and subject to 
many interruptions ; but, if not permanently checked, it may 
gradually extend until it involves a considerable portion of the 
cornea ; and, if the original perforation was extensive, it may 
even implicate the whole of the corneal tissue, and thus be 
transformed into a "total" staphyloma. The walls of the pro- 
jection may preserve, to a great degree, their former transpa- 
rency and delicacy, in which case, either through mechanical 
violence or a sudden contraction of the recti muscles, they fre- 
quently burst. But, in most cases, as the staphyloma enlarges 
the walls increase in thickness, and, when it protrudes between 
the lids, the external irritation frequently excites more or less 
inflammatory action, which tends still further to augment the 
size of the morbid growth. 

ETIOLOGY. — As already stated, the most frequent cause of 
staphyloma of the cornea is ulceration. But it may also be 
produced by wounds and injuries, or by any operation, such as 
flap extraction, which becomes complicated with prolapse of 
the iris. Total staphyloma is frequently caused by ulceration 
or sloughing of the entire cornea. 

TREATMENT. — Internal remedies can have no beneficial 
effect upon staphyloma of the cornea, unless it be in retarding 
its development by lessening inflammatory action. In this 
way some good may possibly result, in particular cases, by the 
administration of such remedies as the inflammatory compli- 
cations may specially indicate. The most approved treatment 
for partial staphyloma, especially if recent, is iridectomy. 
This operation at once lessens the intra-ocular pressure, and 
thus not only arrests the bulging of the* cornea, but may also 
cause it to diminish in size. At a later stage of the affection, 
glaucomatous symptoms may set in, and then, of course, iri- 
dectomy should on no account be omitted. Fortunately for 



STAPHYLOMA OF THE CORNEA. 313 

the success of the operation, the place of election in these 
cases is generally opposite the most transparent portion of the 
cornea, namely, the periphery. In some cases of partial 
staphyloma, it is advisable to combine iridectomy with the 
methodical use of a pressure bandage ; but if, for any reason, 
the latter is not well borne, or if it seems to excite pain or un- 
easiness within the eye, it had best be dispensed with, and the 
eye simply shaded. 

Total staphyloma does not admit of any restoration of 
vision, the only object of treatment being to improve the per- 
gonal appearance of the patient, and relieve him from an an- 
noying and painful disfigurement by removing the projection. 

Of the numerous methods of operating in these cases, we 
shall only mention two, namely, (1) Excision and (2) Borelli's 
operation. 

1. EXCISION. — The lids being widely separated by an 
assistant, the point of a cataract knife (PL I., Fig. 29), with the 
edge turned downward, is made to penetrate the base of the 
staphyloma in such a manner that, when pushed forward and 
made to cut its way out, it shall divide the lower two-thirds of 
the staphyloma in the plane of its base. The collapsed 
growth is then seized by forceps, and the remainder divided 
with scissors ; or, if the operator prefers, a flap may be formed 
from it with which to cover the opening at the base of the 
staphyloma. A pressure bandage is then to be applied, and 
the resulting inflammation moderated by rest and the internal 
administration of Aconite. 

2. Borelli's Operation. — This consists in transfixing 
the tumor by two needles, in such a manner as to form a cross. 
A ligature is then passed round the staphyloma, behind the 
needles or pins, and firmly tied. In the course of three or 
four days the tumor generally sloughs off, and in a week or so 
afterwards the wound is healed. If the staphyloma is small 
or partial, its whole base should be included within the liga- 



V 

314 PRACTICE OF MEDICINE. 

ture ; but if large or total, only a part of it should be em- 
braced, and care should also be taken not to draw the ligature 
too tight, otherwise it may cut through the walls of the tu- 
mor, or suppurative choroiditis may supervene and destroy the 
eye. 

1Q-ANTERI0E SCLERO-CHOROIDAL STAPHYLOMA. 

Sclero-choroidal staphyloma may affect the anterior, later- 
al, or posterior portion of the sclerotica, but is mostly confined 
to the anterior and posterior zones. The latter has already 
been described under the head of "Sclero-Choroiditis Poste- 
rior." The former is no more a primary affection than the 
latter, but is a secondary effect of an inflammation of the an- 
terior part or the whole of the uveal tract ; in other words, it 
may proceed from a partial or total sclero-choroiditis. The in- 
creased tension of the globe distends the sclerotica from with- 
in, while the resistance of the membrane is probably dimin- 
ished by its participation in the inflammation. In this way 
the sclerotica becomes thinned, and raised into prominences of 
various magnitude. These vary in size from that of a small 
grain to a filbert ; or the whole anterior portion of the scle- 
rotica may be raised into one irregular, mulberry-like tumor 
round the cornea, and then the disease is called "Annular 
Staphyloma." As the staphyloma increases, the sclerotica be- 
comes more and more atrophied and discolored, the affected 
part assuming a dusky, bluish-grey appearance, due to the 
shining through of the choroid. The growth of the tumor is 
sometimes very rapid, and is then usually attended with severe 
pain and other symptoms of acute inflammation ; but, as a 
general rule, the progress of the disease is very slow and grad- 
ual, its course corresponding with that of the inflammatory 
affection on which it depends. When the latter becomes 



OPACITIES OF THE VITREOUS HUMOR. 315 

chronic, the staphyloma generally remains stationary, or slowly 
progresses ; but during periods of exacerbation, the eye be- 
comes painful and the disease makes perceptible progress. 

TREATMENT. — During the early stages of the affection, 
the treatment is the same as that for Choroiditis (which see). 
But when the staphyloma has existed for some time, and is 
large, we may have to remove it by an operation. For this 
purpose we may adopt either of the methods described under 
the head of "Staphyloma of the Cornea and Iris." 

II -OPACITIES OF THE VITEEOUS HUMOR. 

Opacities of the vitreous are of two distinct forms, or 
classes — the diffuse, and the filiform or membranous. The dif- 
fuse variety presents itself in the form of a greyish mist or 
nebulosity, scattered here and there through the vitreous hu- 
mor, or spread out like a veil over the fundus, and giving a 
blurred appearance to the vessels of the retina and optic disc. 
This form developes rapidly, extends quickly through the en- 
tire vitreous, and clears up just as quickly, appearing and dis- 
appearing from time to time, according to the condition of the 
vascular envelope of the vitreous, which serves as the develop- 
ing membrane. When these changes occur very suddenly, 
there is reason to apprehend the most serious consequences, as 
they are frequently succeeded by detachment of the retina. 
If, however, the inflammation on which the opacity depends 
takes a permanently favorable turn, the vitreous may clear up 
and return to its normal condition 

Associated with the diffuse form, we frequently meet with 
various circumscribed opacities, both filiform and membranous, 
consisting of the debris of cells, or the remains of blood 
effusions, floating about in the vitreous, and assuming a great 
variety of forms. Examined with the ophthalmoscope, they 
are seen to be dark, fixed or floating bodies, of a filiform, 



3l6 PRACTICE OF MEDICINE. 

reticulated or membranous character ; or they may be so fine 
and numerous as to give an obscure and hazy appearance to 
the whole fundus. 

Treatment. — This to be successful must be directed to 
the removal of the cause, which, as we have seen, is generally 
some form of choroiditis, or other inflammatory affection of the 
deeper structures of the eye. Arn., Gels., Ham., Kali iod., 
Lach., Merc, and Sulph. have acted very favorably in many 
cases, and are worthy of special attention. Ars., Bell., Caust., 
Kal., Lye, Phos., Prun., SiL, and Sol. n. have also been recom- 
mended, and deserve notice. The absorption of opacities 
arising from extravasation of blood into the vitreous, has been 
hastened by the application of a compress bandage. Benefit 
often accrues, also, from attention to the general health, 
especially when the affection is aggravated by some functional 
derangement of the system. 

12.-DETACHMENT OF THE RETINA. 

AMOTIO RETINA. 

Detachment of the retina occurs whenever serum is 
effused between it and the choroid. At first it is always 
partial, and confined to the periphery ; but it may afterwards 
spread in every direction, especially towards the optic disc. 
It usually takes place in the lower half of the fundus, 
probably in consequence of the fluid immediately gravitating 
to that part. The outline of the detachment, as viewed with 
the ophthalmoscope, is generally somewhat irregular, varying 
according to the amount of sub-retinal effusion. When the 
detachment is large and prominent, it is frequently thrown 
into folds, which are usually most conspicuous near the 
circumference of the fundus, on which they sometimes cast a 
distinct shadow. The color of the detached retina, which 



DETACHMENT OF THE RETINA. 317 

chiefly depends upon that of the fluid beneath, is of a yellowish, 
greenish, or bluish-grey tint, and often exhibits a marked 
contrast with the usual bright red reflex of the normal retina. 
These features of the disease are generally sufficiently 
distinctive for the ready recognition of advanced cases ; but 
in very slight degrees of detachment, a much closer inspection 
is required to clear up the diagnosis. We notice, first, that the 
vessels are darker than those on the normal retina ; that they 
bend more or less abruptly over the border of the detachment, 
and pursue a crooked and tortuous course on the folds, 
between which they frequently disappear; that they quiver 
with every movement of the undulating membrane ; and that 
they are somewhat closer to the observer than those on the 
normal retina. We notice also that those appearances are 
generally more conspicuous the nearer we approach the 
circumference of the fundus. 

Vision is impaired in proportion to the degree of detach- 
ment. The patient first notices a faint cloud waving before 
him, at a point in the field of vision corresponding to the 
sub-retinal effusion. Hence, if the detachment occurs in the 
lower half of the fundus, the obscurity will be in the upper 
half of the visual field, and vice versa. Objects generally 
seem more or less distorted, exhibit slight wave-like or undula- 
tory movements, and appear bordered with a colored ring. 
The sight is likewise disturbed with photopsies, arising from 
retinal irritation; and also by movable opacities of the vitreous, 
which appear as black specks and spots, of various sizes and 
shapes, floating about in the field of vision. 

Etiology. — The causes which give rise to detachment 
of the retina are not always manifest. Sometimes it can 
be traced directly to a blow or fall. In other cases it is 
found to arise from intra-ocular hemorrhage, occurring in 
the course of some inflammatory affection of the choroid 
or retina. Thus, we have seen it to occur very frequently 



3l8 PRACTICE OF MEDICINE. 

in the course of sclero-choroiditis posterior, in consequence 
chiefly of the elongation of the optic axis, which, by causing 
a separation of the vitreous, favors the detachment of the 
retina. It is also frequently associated with retinitis, 
especially the exudative variety. 

PROGNOSIS. — This is mostly unfavorable. Occasionally, 
slight detachments may remain stationary, or may even 
disappear, the sub-retinal fluid becoming absorbed, and the 
affected membrane regaining its functions. But such favorable 
results are not to be expected. In the vast majority of cases 
the disease is progressive, the detachment slowly extending, 
accompanied by frequent inflammatory attacks and exacerba- 
tions, until finally it terminates in total blindness. When the 
detachment is the result of accident, the disease is generally 
limited to one eye, and is much more favorable;* but when 
associated with myopia, or when it depends upon sclero- 
choroiditis posterior, each eye is usually affected, the same 
cause operating in both. 

Treatment. — If seen shortly after the detachment 
occurs, the patient should be confined to his room, and if 
possible, to his bed. The eyes should also be carefully ban- 
daged, as this not only serves to exclude the light, but hastens 
absorption. Atropine should be immediately instilled, chiefly 
with the view of preventing accommodation ; but its use 
should not be pushed too far, as the sudden reduction of the 
intra-ocular pressure is liable to excite temporary hyperaemia 
of the vessels of the choroid and retina, and by causing an 
effusion of blood, increase the detachment. 

Gelseminum is one of our most promising internal 
remedies for this affection, rapidly promoting absorption in 
recent cases, both traumatic and inflammatory. Much benefit 
has also been derived from the administration, in suitable cases, 
of Apis, Ars., Aur., Bry., Dig., Hep., Kali iod., Merc, and Rhus. 



*See Dr. Boynton's Case, p. 244, et. teg. 



HORDEOLUM. 319 

Temporary improvement has been obtained by puncturing 
the sac by means of a sickle-shaped needle, and permitting 
the fluid to escape from beneath the retina. The needle is 
passed perpendicularly through the sclerotica behind the lens, 
and having penetrated seven or eight lines into the vitreous, 
its point is turned towards the detachment, which is then 
divided as the instrument is withdrawn. Especial care must 
be taken not to cause intra-ocular hemorrhage by wounding 
the choroid. The operation, though unattended with any 
immediate danger, is not always successful ; and as it appears 
in many cases to have "hastened the atrophy of the eye by 
inciting a degenerative irido-choroiditis," its usefulness as a 
remedial measure is, to say the least, very questionable. 



DIV. III. OPHTHALMIC TUMORS. 

In the technical sense of the word, a "tumor" is "a cir- 
cumscribed substance produced by disease, and different in its 
nature from the surrounding Jparts." In a broader and more 
general sense, however, the term may be used to denote any 
morbid enlargement of a part, whether different in its nature 
from the neighboring tissues, or not ; and it is in this less- 
restricted sense that we shall make use of it. 

1 -HORDEOLUM, OR STYE. 

This miniature boil is too familiar to need particular de- 
scription. It is not, as was formerly supposed, an inflammation 
of a Meibomian gland, but of the connective tissue of the edge 



320 PRACTICE OF MEDICINE. 

of the lids. As a general rule, only one boil occurs at a time, 
but in some cases there are several ; and it is no uncommon 
thing for one to follow another in regular succession, thus 
prolonging the disease for several months. The inflammation 
is generally confined to the immediate vicinity of the stye, but 
if highly acute it may extend to the entire lid, which becomes 
very red and cedematous ; and even the ocular conjunctiva 
may become inflamed and chemosed. In such severe cases 
there is apt to be considerable feverishness and constitutional 
disturbance. But generally the disease runs a less acute, and 
in some cases a chronic course ; and although the swelling is 
extremely sensitive to the touch, it soon terminates, either in 
resolution, or, which is more common, in suppuration, the pur- 
ulent matter being discharged from the apex of the stye, 
mixed with small masses ol disintegrated connective tissue. 

Hordeolum is generally regarded, and justly so, as an 
indication of an unhealthy state of the constitution. It is most 
commonly met with in scrofulous and enfeebled subjects, or in 
those whose health is broken down, especially individuals 
whose constitutions are undermined by dissipation, or in whom 
there co-exists some derangement of the digestive or uterine 
organs. 

TREATMENT. — If seen sufficiently early, we may bring 
about resolution by the use of cold compresses and Aconite ; 
but in most cases it is advisable to hasten the suppurative 
process by warm applications, giving at the same time Hepar 
or Pulsatilla internally, and subsequently, Graph., Staph., 
Sulph., or Thuja. The following remedies are also useful in 
preventing the recurrence of styes : — Alum., Ambr., Caust, 
Con., Ferr., Lye, Merc, Nat. m., Phos. ac, Rhus, Seneg., Sep., 
Sil., and Stann. 



DISEASES OF THE EYE. 32 1 



2.-CHALASI0N. 



This is a small tumor, or cyst, originating in the tarsus, 
and due to inflammatory or other changes of the Meibomian 
apparatus. Its usual appearance is that of a small, rounded, 
isolated tumor, about the size of a pea, situated just beneath 
the conjunctiva or skin, and at a little distance from the edge 
of the lid. It occurs most frequently in the upper lid, but 
sometimes in the lower one, and more rarely in both. It 
occasionally becomes inflamed and traversed by enlarged 
vessels ; and if the inflammation is very acute, it may give 
rise to suppuration and the formation of a small cystic abscess. 
In most cases, however, the inflammation is of a chronic char- 
acter ; and the contents of the cyst, instead of being purulent, 
are sometimes glairy or gelatinous, sometimes curdy, and 
sometimes fatty or sebaceous. 

Debility seems to favor its development, as it is of frequent 
occurrence after confinement or prolonged nursing ; but its 
connection with an impaired state of health is not so evident 
as in stye, with which it sometimes co-exists. It is of remark- 
ably slow growth, many months elapsing before it attains its 
full development. 

Treatment. — If the tumor is soft and recent, we may 
sometimes cure it by administering Merc, precip. rub., or Kali 
iod., internally, at the same time that we use an ointment of 
these remedies externally. We have known the tumor to dis- 
appear without treatment, but this is a rare occurrence. In the 
majority of cases, even after the faithful use of indicated rem- 
edies and due attention to the general health, we have been 
obliged to resort to the knife. The operation is very simple. 
The lid having been everted, a crucial incision is made into the 
tumor with a scalpel or narrow knife, and if the contents are 
not sufficiently fluid to escape at once, they may be pressed 
out with the fingers, or scooped out with any convenient instru- 



322 PRACTICE OF MEDICINE. 

ment. No after-treatment is generally required. It is well to 
inform the patient that he should not expect any reduction in 
the size of the tumor for several days, and that the swelling 
may even undergo a temporary increase, from bleeding within 
the cyst. The inflammation excited by the operation will 
cause contraction, and in the course of two or three weeks, the 
cyst, and the thickened tissues around it, will disappear. If 
the tumor return, which is very rarely the case, the operation 
should be repeated, taking care to excite sufficient adhesive 
inflammation to insure the obliteration of the cyst, by lightly 
touching its interior with a pointed crayon of nitrate of silver ; 
or, what is frequently more convenient, by dipping a silver 
probe in nitric acid and cauterizing the cavity with the nitrate 
of silver thus extemporaneously prepared. 



3 -DERMOID TUMORS. 

These were formerly called warts, moles and liorns. The 
former are usually small, roundish and projecting. They are 
of various degrees of consistency, some being quite soft and 
fleshy, while others are hard and cartilaginous. They also 
vary greatly in color, being in some cases white, in others yel- 
lowish, red, reddish brown, or dark brown. The surface of the 
wart or mole is sometimes smooth, sometimes rough or granu- 
lar, and sometimes it has a number of short and delicate, or 
long and coarse hairs springing from it. These tumors con- 
sist, according to Virchow, "of a pad of connective tissue and 
elastic filaments, covered by a thick layer of epithelium, in 
which are situated the hair-follicles, either with or without 
accompanying sebaceous glands." They may be confined to 
the ciliary margin or to the outside of the lid, or they may 
occupy both. They also occasionally appear on the conjuncti- 
va, in the form of small, flesh-colored tubercles, either singly 



SEBACEOUS TUMORS. 323 

or in clusters. These mucous warts bear a strong resemblance 
to those that occur on the prepuce. Dermoid tumors of a pale, 
whitish-yellow color, one or two lines in diameter, smooth or 
lobulated, and either with or without projecting hairs, are also 
sometimes met with on the cornea. 

The so-called "horns," according to Wilson, are "accretions 
of inspissated sebaceous matter on the edges of the lids, which 
owe their origin to the drying and hardening, as fast as it es- 
capes, of the contents of the follicles that furnish the material 
for their growth." 

TREATMENT. — Dermoid tumors are mostly congenital, and 
generally require excision. Warts on the lids are said to have 
disappeared under the use of one or more of the following 
remedies, and if the patient is averse to having them snipped 
off, which is a very trifling operation, there can be no harm in 
trying them : Bar. c, Calc. c, Caust., Hep., Nit. ac, Kali bic, 
Lye, Sep., SiL, Sulph. and Thuja. 



4.-SEBACE0US TUMORS. 

These are generally met with in infants and young child- 
ren. They appear most commonly at the upper margin of the 
orbit, near the external extremity of the eyebrow, but they are 
sometimes seen at the internal or nasal end. When first no- 
ticed they are about the size of a small pea, and are so loosely 
covered by the integument that the latter may be easily 
pinched up into a fold. They always grow very slowly, are 
unattended by pain or redness, and seldom attain any consid- 
erable magnitude, the largest not exceeding an inch or so in 
diameter. When opened they are found to consist of a com- 
pact cyst, the posterior wall of which is somewhat thickened, 
and generally adherent to the periosteum of the orbit. The 
contents of the cyst are sebaceous, containing fat molecules 



324 PRACTICE OF MEDICINE. 

and broken-down epithelial cells, mixed in varying proportions 
with short and imperfectly-formed hair. The tumor appears to 
be congenital. 

Treatment. — The proper treatment of sebaceous tumors 
is operative. Perhaps by a careful selection of our drugs, 
based chiefly upon constitutional symptoms, we may, in some 
cases, effect their absorption ; but we have never witnessed 
their removal in this way, and unless the general health can 
be benefited by it, it is not worth while to waste time by de- 
pending upon medical treatment. If, however, the patient is 
opposed to operative procedures, we may try the following 
remedies, which have received the endorsement of able physi- 
cians : Bar. c, Calc. c, Graph., Hep., Nit. ac, Sil., and Sulph. 

Sebaceous, like other subcutaneous cystic tumors, should 
be carefully dissected out, or rather eneucleated, the handle, 
instead of the edge, of the knife being used whenever practica- 
ble ; for if the cyst be opened and its contents allowed to es- 
cape, the accident will greatly increase the difficulty of remov- 
ing the whole of the tumor. If this should happen, however, 
it will be advisable to lighly cauterize the remaining portions 
of the cyst with nitrate of silver, in order to prevent the return 
of the tumor. 

5.-CYSTI0 TUHOBS. 

Vesicular and other cystic tumors, the contents of which 
are sometimes watery and sometimes glairy, frequently occur 
about the lids. When of long standing, they are often more or 
less pedunculated, and either overlap the edge of the lid or ex- 
tend back into the orbit. They are usually connected with 
some portion of the conjunctiva, forming, for the most part, 
small, pinkish, translucent tumors, the walls of which are gen- 
erally very thin, and but loosely connected with the conjunc- 
tiva. 



CYSTIC TUMORS. 325 

Cysts of the iris are less frequently met with, and are 
usually the result of some injury to that membrane. They 
generally spring from the surface of the iris in the form of 
small vesicles, which may be either translucent or opaque. 
The contents may be limpid and transparent, sebaceous and 
soft, or hard and •cartilaginous. In most cases they excite 
considerable irritation and may even give rise to iritis. 

Orbital cysts also occur, some of which, as above stated, 
spring from the glandular structures of the conjunctiva, whilst 
others are developed from the follicles of the lids. The 
contents of these cysts are of the most varied character, serous, 
glairy, sanguinous, fatty, etc. Some also contain hair, others 
hydatids. The hydatids are the echinococci and the cysticerci. 
The former, varying in size from a pea to a filbert, have been 
known to exist in such quantities, that when emptied from the 
cyst they filled a tea cup half full. These tumors generally 
grow very slowly, and when small are usually attended with 
but little inconvenience ; but as they increase in size the 
eyeball gradually becomes more and more protruded, and the 
sufferings of the patient are often most intense. 

The cysticercus occurs most frequently within the eye. 
It is occasionally seen in the anterior chamber, but its most 
frequent seat is in or under the retina. At first it excites 
severe irritation, but after a while the eye becomes accustomed 
to its presence, and it may remain for weeks and months 
without giving rise to any great inconvenience ; sooner or 
later, however, it sets up violent inflammation, and the eye is 
finally destroyed by irido-choroiditis. 

Treatment. — Vesicular and other small cystic tumors 
generally require nothing more than a simple puncture ; but 
when of a certain size the cyst must be removed or the tumor 
will be pliable to return. Cysts of the iris will also require 
excision, together with the portion of membrane to which they 
are attached, as simply puncturing or lacerating them proves 



326 PRACTICE OF MEDICINE. 

unsuccessful. ' It should be remembered, however, that this 
operation, even when combined with iridectomy, is not entirely- 
devoid of danger, having in one instance given rise to severe 
purulent cyclitis. The greatest care should therefore be taken 
to guard against inflammatory complications, by removing 
every portion of the cyst. Orbital cysts containing fluid 
should be emptied of their contents, the operation being 
repeated as often as may be necessary ; but other forms 
should, if possible, be dissected out. 



6.-FATTY AND OTHER TUMORS. 

1. Milium. — This is a small white tumor, about the size 
of the head of a large pin, and is generally seated at or near 
the edge of the lid. The cyst wall consists of a thin but 
dense membrane, containing a soft white substance like boiled 
rice. These tumors usually occur in elderly persons, and 
occasion little or no inconvenience, unless they happen to be 
numerous, or appear in clusters. 

2. Moluscum. — This tumor is of the same nature as 
milium, but larger, and generally seated a short distance from 
the edge of the lid. It posseses little or no elasticity, 
retaining for some time any form into which it may be pressed. 
In this respect it differs sensibly from the 

3. Fatty Tumor. — This is of frequent occurrence about 
the eyelids, and is firm and elastic to the touch ; it is further 
characterized by being smooth, of a somewhat lobulated form, 
and of extremely slow growth. It is occasionally observed 
on the ocular conjunctiva, especially in the vicinity of the 
lachrymal gland. In these cases it appears to be due to an 
hypertrophy of the adipose tissue of the orbit. Sometimes 
these tumors attain such proportions as to displace the eyeball, 
and press injuriously upon the lachrymal gland. 



N^EVUS MATERNUS. 327 

4. Polypi. — These are small condylomatous elevations, of 
a pinkish color, attached to the conjunctiva by a distinct 
pedicle, and generally seated near the semilunar fold They 
sometimes attain the size of a pea or hazel nut, and protrude 
between the lids. 

Treatment. — Milia and molusca simply require to be 
pricked, and their contents squeezed out. In removing fatty 
tumors, care should be taken to sacrifice as little of the 
conjunctiva as possible, and to unite the edges of the incision 
by a fine suture. Polypi should be snipped off with scissors, 
and the hemorrhage arrested by touching the cut surface 
with nitrate of silver, which will also be likely to prevent a 
return of the disease. 



7.-NJEVUS MATERNUS. 

TELANGIECTASIS. 

This affection, the name of which is now restricted to 
congenital tumors characterized by peculiar and excessive 
vascularity, is generally met with on the eye-brow and upper 
lid. It is also occasionally found on the conjunctiva, and 
very rarely on the iris. These growths are generally divided 
into an arterial or active, and a venous or passive form ; but 
this distinction, is quite arbitrary, and we shall find it more 
convenient to describe them according to the positions they 
occupy, as cutaneous, subcutaneous, and mixed. The cutan- 
eous variety varies bqth in depth and extent, appearing in 
some cases like a mere stain, and in others like a circumscribed 
mass of blood-vessels. The subcutaneous form, being deeper, 
is not so well defined, and is either colorless or of a light 
bluish tint, according to its depth from the surface. When 
deep, it bears a close resemblance to the common fatty tumor. 



328 PRACTICE OF MEDICINE. 

Most naevi may be diminished in size by pressure, the blood- 
vessels being more or less emptied by it, but as soon as the 
pressure is removed they refill. Some are firm and distinctly 
pulsatile to the touch, while others are soft and impart no 
arterial thrill to the fingers. They all become distended 
when the patient stoops, screams or struggles, and when 
superficial they assume at such times a very dark and tense 
appearance. On account of their vascularity, they also bleed 
profusely on the slightest injury. 

TREATMENT. — Naevi after reaching a certain size frequently 
remain almost stationary ; in other cases they slowly diminish ; 
and sometimes they disappear altogether. Mere stains seldom 
undergo natural resolution, but the bluish superficial naevus is 
more apt to disappear spontaneously than the scarlet variety. 
The process is said to be hastened in some cases by the use of 
the following remedies : — Calc. c, Carb. v., Cund., Fluor, ac, 
Lach., Lye, Nux v., Phos., and Thuja. 

If it becomes necessary to interfere surgically, the best 
plan is to endeavor to procure the obliteration of the naevus, 
by exciting adhesive inflammation in it. This may be readily 
accomplished by passing a number of fine silk threads, soaked 
in a solution of the perchloride or persulphate of iron, across 
the tumor in different directions, and leaving them in for a 
week or two. The subcutaneous ligature is a less convenient 
but very effectual operation. The ligature is applied in 
different ways, according to the size and situation of the tumor. 
If large, it is best to divide it into sections, corresponding to 
the peculiar shape of the tumor, and ligature each portion 
separately ; but if small, a single thread may suffice. Another 
useful plan is to break up the substance of the growth 
subcutaneously, by means of a cataract needle, repeating the 
operation from time to time, and in the intervals to keep up 
pressure upon it. But the most eligible method of operating 
is by electrolysis, inasmuch as it leaves no scar or disfigure- 
ment, and is not attended with any pain or danger. 



DISEASES OF THE EYE. 329 

8.-FIBE0US TUMORS. 

These tumors are met with in the eyelids, conjunctiva and 
orbit. In the eyelids they form small, hard, circumscribed 
elevations, which are sometimes painful to the touch. In 
some cases they assume a cartilaginous or bony character. 
They are mostly seated in the submucous tissue, and are 
readily brought into view by everting the lid. 

In the ocular conjunctiva these fibromata take the form of 
Pinguecula. The latter consists of hypertrophied conjunctival 
and episcleral tissue, and is generally situated close to the edge 
of the cornea. It is a small, flat, roundish or triangular body, 
of a yellowish-white color, and bears a slight resemblance to 
pterygium, for which it is sometimes mistaken. It does not, 
as might be inferred from its name and appearance, contain 
any fat, but is made up chiefly of epitheliel cells and connective 
tissue. Pinguiculae generally occur in old people, and are 
probably due to a chronic irritation of the conjunctiva in 
consequence of external injuries. 

Fibrous tumors of the orbit spring from the periosteum, 
to which they often adhere by a broad base ; but the more 
movable ones are usually attached to the edge of the orbit by 
one or more pedicles. Some of them are hard and smooth, and 
some are soft and lobulated. The former are generally 
small, circumscribed, and more or less movable. The latter, 
which sometimes attain a very great size, extend in some cases 
deeply into the orbit, and may even involve the bones of the 
head and face. 

Treatment. — The only successful treatment for fibrous 
tumors is operative. We are convinced that much valuable 
time is often lost by practitioners of our school, in vain 
attempts to disperse such tumors by local applications and 
medicines. Those attached to the orbit, if capable of being 
readily extirpated, should be removed early, especially if they 



330 PRACTICE OF MEDICINE. 

encroach upon, or are actually within its cavity. No such 
operation should be undertaken, however, without duly 
weighing all the circumstances of the case, some of which 
may render the case exceptional. Thus, the history 
and situation of a tumor may be such as not to threaten 
mischief, when its removal would in all probability 
injure or destroy the sight. In this case, of course, no good 
surgeon would undertake an operation. On the other hand, 
if the growth of the tumor gives rise to cerebral symptoms, 
the surgeon should not hesitate to sacrifice the eyeball, if 
necessary, in order to remove it, and even incur the risk of 
exciting considerable inflammation. 



9.-SAHC0MAT0US TUMORS. 

Sarcoma occurs primarily in all parts of the eye and 
surrounding tissues. It first appears in the form of nodules, 
which frequently become quite large, and give to the growth a 
very irregular appearance. It is characterized by a prepon- 
derance of cellular elements, which vary greatly in form and 
size, being spindle-shaped, stellate, oblong, circular, etc. 
Sometimes the cells contain pigment, and then it is called 
melanotic sarcoma. It is not of a benign character, neither 
is it so malignant as cancer, but rather between the two, 
developing first in homologous, and afterwards in heterologous 
tissues. Its structure is equally diverse, sometimes approaching 
one type and sometimes another of the connective tissue 
group, giving it at various times more or less of a fibrous, 
mucous, gliose, melanotic, medullary, cartilaginous, or bony 
character. It appears much the most frequently in the 
choroid, where it sometimes developes rapidly ; but generally 
its growth is very slow and interrupted, giving rise to symptoms 
of glaucoma, usually of a chronic character. Sometimes the 



GLIOMA RETINA. 33 1 

disease originates in the ciliary body, and when it has become 
sufficiently developed, makes its appearance in the anterior 
chamber, in the form of a dark brown tumor; or it may extend 
backwards in the same manner into the vitreous. It is also 
frequently found in the orbit, being, according to Virchow, 
generally developed from the adipose tissue behind the eye. 
After a time it pushes the eyeball out of the orbit, and 
appearing beneath the conjunctiva in the form of round, firm 
protrusions, finally assumes a fungoid character. Or the 
disease may grow inward, and after reaching the dura mater, 
invade the cranium. After implicating the neighboring 
tissues, the disease generally ends in metastasis. 

Sarcoma is less common in childhood than in adult life ; 
but it frequently developed from warts or maculae in the 
integuments of the lids, which were either congenital or 
observed in infancy. These often remain unchanged till old 
age, when they suddenly become sensitive and painful, and 
gradually take on the character of sarcomatous tumors. 

Treatment. — The only safety in these cases is in complete 
extirpation. If the tumor is intra-ocular, the sooner the eye 
is enucleated after the disease is recognized, the better. 



10 -GLIOMA EETINJE. 

Glioma retinae is the name given by Virchow to the 
medullary fungus of the retina, heretofore known as enceph- 
aloid cancer, or fungus haematodes. It is mostly, and perhap? 
entirely, a disease of childhood ; for while it is not a very 
uncommon affection, not a single undoubted case of it, 
according to Hirschberg, has, up to the present time, been 
observed in persons over twelve years of age. 

SYMPTOMS. — The loss of sight is usually the first symptom 
that attracts attention. The pupil is then seen to be some- 



332 PRACTICE OF MEDICINE. 

what widely dilated, and through it, upon careful examination, 
may often be discerned a glistening-, yellowish reflection, 
formerly called the "amaurotic cat's eye." Examined with 
the ophthalmoscope, we find the affected portion of the retina 
somewhat mottled, thickened and opaque. As the morbid 
growth increases and becomes more prominent, it protrudes 
more and more into the vitreous humor, where it presents the 
form of a nodulated yellowish-white mass, over which ramify 
numerous blood-vessels. The latter inosculate freely with 
each other, and also with those more deeply seated, the growth 
being characterized by great vascularity. The tumor con- 
tinuing to enlarge, the lens becomes absorbed, or pushed 
forward along with the iris towards the anterior portion of the 
globe, where sooner or later perforation usually takes place, 
and the morbid growth sprouts forth in the form of a dark-red 
and easily-bleeding fungus. (Fungus hcematodes). 

Sometimes the glioma appears first in the external layers 
of the retina, and then it generally soon perforates externally. 
This condition may be suspected if the movements of 
the globe are much limited, and the eyeball protruded. 
When the tumor penetrates deeply into the vitreous 
humor, the intra-ocular tension increases, and this 
furnishes a diagnostic sign of great importance. Primary 
glaucoma being almost entirely a disease of adult life, 
a marked increase of the intra-ocular tension occurring 
in young children, should always excite suspicion. As 
for the differential diagnosis between simple detachment 
of the retina and that which occurs in glioma, we have only 
to remember that in the former the intra-ocular tension 
is often diminished. 

Occasionally the disease, at a certain stage of its progress, 
is very difficult to distinguish from simple choroiditis; in point 
of fact, the disease sometimes assumes the character of an 
irido-choroiditis, with commencing atrophy, the intra-ocular 



CARCINOMATOUS TUMORS. 333 

tension being diminished, and the pupil obstructed by lymph. 
These symptoms are generally due to suppurative choroiditis, 
but in some rare cases they are said to be caused by suppuration 
of the cornea. But here the similarity ceases. The atrophy 
is often accompanied with severe paroxysms of pain, while 
the eye is perhaps no more sensitive to the touch than usual. 
At a later period the usual symptoms of glioma again manifest 
themselves, and the disease progresses in the manner already 
described. 

That the disease is malignant we think there can be but 
little doubt. The optic nerve frequently becomes implicated, 
and in this way the affection may be propagated to the brain, 
giving rise to secondary glioma or inflammation of that organ. 
When once the adipose tissue of the orbit becomes implica- 
ted, the progress of the disease is very rapid. 

TREATMENT. — The only rational treatment for this, as well 
as every other malignant disease of the eye, is the immediate 
enucleation of the globe. Cases are on record in which, after 
the lapse of several years, there was no return of the disease. 
Care should be taken in performing the operation to excise 
the optic nerve as far back as possible, in order to include the 
whole of the diseased structure ; and if the disease is found to 
have extended to the orbit, it would be well to apply the 
chloride of zinc paste to the orbital cavity, as recommended 
under 



11- CARCINOMATOUS TUMORS. 

Carcinoma differs but little in general appearance from 
sarcoma. According to Virchow, "the disease is recognized 
by the alveolar formation of its stroma, and the epithelial 
character of its cellular elements." It may occur in any part of 
the eye and surrounding tissues, but generally originates extra- 
ocularly. It is of the most malignant and destructive nature, 



334 PRACTICE OF MEDICINE. 

invading and destroying the most heterologous tissues, contam- 
inating the circulation, and spreading both by assimilation and 
metastasis. It is also a very painful disease, being 
usually attended with more or less suffering from the 
very commencement. It may be divided into three 
principal forms, namely : (a) the epitheliel, (b) the medullary, 
and (c) the scirrhus — melanotic cancer being only a variety of 
of the medullary. 

A.— Epitheliel Cancer. 

This form of cancer, which is always supeiflcial, rarely 
commences upon the lids or conjunctiva, but spreads to these 
parts from the skin of the nose, forehead or cheeks, invading 
most frequently the lower lid, near the inner canthus. It 
seldom attacks the young, being much more common in those 
somewhat advanced in life. It generally makes its appearance 
in the form of small, hard, circumscribed elevations, or 
tubercles, feeling like knots beneath the skin. These slowly 
enlarge and increase in number, until by coalescence they 
assume the form of warts or small thickened crusts. In this 
condition they may remain for a long time, but sooner or later 
itching or uneasiness begins to be felt, the surface is rubbed or 
otherwise irritated, and then ulceration sets in. A thin 
yellowish discharge oozes from the ulcerated surface, which 
drys and forms a dark rough crust. The disease now begins 
to spread in every direction. Sometimes the ulcer becomes 
temporarily healed over, but it soon re-opens, and the ulceration 
is renewed. In this way the malady proceeds, irregularly 
but gradually eating its way along the surface and through 
the lid, until ultimately it exposes the conjunctiva, and extends 
perhaps to the orbit. Up to this time the disease is generally 
attended with but little pain ; but as soon as it attacks the 
deeper tissues, especially those of the globe, acute pain is felt, 



CARCINOMATOUS TUMORS. 335 

resulting partly from exposure of the nerves, and partly from 
pressure of the tumor upon them. 

A striking peculiarity of epitheliel cancer is the slowness 
with which it advances. Several years may pass before 
ulceration sets in, and many more may elapse before it makes 
any considerable progress, provided the general health of the 
patient remains good, and the sore is judiciously treated. 
Ultimately, however, the cancerous cachexia is induced, and 
then, if not before, the disease advances with the most 
destructive rapidity. 

B— Medullary and Melanotic Cancer. 

Medullary cancer is distinguished as intra- or extra-ocular, 
according as it makes its first appearance in the choroid, or on the 
walls of the orbit. It is easily recognized by its soft consistence, 
and by the fungous character (f?mgns hcematodes) which it 
presents after the tumor bursts from the orbit, or is released 
from pressure by ulceration. When connected with the orbit, 
the tumor may be closely adherent to the periosteum, or it 
may be but loosely attached to it. It may increase rapidly in 
bulk, invade and destroy the neighboring tissues, and extend 
into the adjoining cavities and along the optic nerve to the 
brain ; or it may protrude externally, and form luxuriant 
fungous masses, giving rise to severe pain, and such a profuse 
discharge and frequent hemorrhage, as to bring the 
case to a speedy and fatal termination. On making a 
microscopical examination of the tumor, we discover large 
areolar spaces, filled with variously shaped cancer cells, similar 
to those described under the head of sarcoma. Unlike 
sarcoma, however, the medullary tumor makes a much more 
rapid progress, leads much earlier to metastatic affections, and 
is consequently far more apt to return after extirpation. (See 
Glioma Re tines). 

As melanotic cancer is but a variety of the medullary, and 



336 PRACTICE OF MEDICINE. 

differs from it chiefly in containing a greater or less amount of 
pigment in its cells, it is unnecessary to describe it in detail. 
The amount of pigment may be so great as to give the tumor 
a deep sooty-black color, streaked here and there with various 
shades of brown or gray. It is the most dangerous variety of 
cancer, and exceedingly prone to recur within a very short 
time after extirpation. 

C— Soirrhus Cancer. 

Scirrhus is so called from the stony hardness which 
characterizes it in whatever tissue of the body it may be found. 
It seldom appears before the middle period of life, and generally 
developes very slowly. Its occurrence in the orbit is 
probably due to some injury or prior inflammation ; at least it 
has been seen to follow a blow or other injury, but more 
commonly it is preceded by repeated attacks of inflammation, 
generally of an intractable nature. 

TREATMENT OF CANCEROUS TUMORS. 

The only proper treatment of any form of cancerous 
tumor of the eye, consists in prompt eneucleation of the 
eyeball, and the complete extirpation of the morbid growth. 
In order to destroy any portions of the tumor which cannot be 
reached with the knife, it is recommended to dress the raw 
surface with the chloride of zinc paste, spread upon strips of 
lint. The paste may be prepared by rubbing up one part 
by weight of the chloride of zinc with four parts of flour, and 
adding sufficient tincture of Conium to make a paste of the 
proper consistency. 



DISEASES OF THE EYE. 33? 



DIV. IV.— CATARACT. 



Cataract is a partial or general opacity of the crystalline 
lens, of its capsule, or of both the lens and capsule combined. 
The first is called lenticular, the second, capsular, and 
the third, capsulo-lenticular cataract. The term false cataract 
was applied by the old authors to deposits of lymph in the 
pupil which have become permanent. This condition, which 
is almost always associated with lenticular cataract, has already 
been sufficiently considered. (See Iritis) 

Lenticular cataracts are divided into two general classes, 
namely, (i) the cortical, or soft cataract; and (2) the nuclear, 
or hard cataract. This classification, though not strictly 
correct, is most convenient for obtaining a general notion of 
the subject; while the exceptional forms will be best under- 
stood by considering them in connection with those to which 
they are most nearly related. 



1 -SOFT CATARACT. 

CORTICAL OR CONGENITAL CATARACT. 

The characteristic feature of soft cataract is, that, although 
the whole lens may be opaque, it contains no hard nucleus. 
It occurs in subjects under thirty-five or forty years of age, 
and is the most common form of congenital cataract. It is 
divided into two principal varieties, the lamellar, and the 
cortical. 

A.— Lamellar Cataract. 

Lamellar cataract is usually congenital, but as it interferes 
very little with vision, it may long remain undetected. It is 
distinguished by the fact that the opacity, which is generally 



338 practice of Medicine. 

of a delicate greyish, or bluish-grey tinge, is partial, central 
and uniform, being surrounded by a transparent or pellucid 
border, and not increasing in density towards the pole, as 
would be the case if the nucleus was affected. Examined by 
the ophthalmoscope, when the light falls perpendicularly upon 
the cataract, the opacity appears as a dark, sharply-bounded, 
circular spot, through which the fundus presents a uniform 
reddish-brown appearance, and beyond the edges of which the 
details of the retina may be distinctly seen. But the diagnosis 
is best made out by oblique illumination. The cataractous 
portion of the lens then appears surrounded by a dark black 
ring, caused by the heads of the ciliary processes shining 
through the transparent margin of the lens. But this uniform 
and sharply-bounded central opacity continues only so long as 
the cataract is stationary. When progressive, the superficial 
layers are affected with a cloudy or striated opacity, giving it 
more or less of a radiated appearance, the striae extending 
from the central portion into the cortex, and marked here 
and there by various minute inequalities. The smaller the 
opaque specks, and the fewer and more delicate the streaks, 
the slower is supposed to be the progress of the cataract, and 
vice versa. 

A fair degree of vision is usually enjoyed by patients 
affected with lamellar cataract ; but the sight is always greatly 
improved by dilating the pupil with Atropine, in consequence of 
bringing into use the peripheral or unaffected portion of the 
lens. Thus, patients who, previous to dilatation of the pupil, 
were barely able to make out the heaviest type, have after- 
wards been able to read with ease the finest print. 

B.— Cortical Cataract. 

This "form of cataract may commence in any portion of 
the cortical substance of the lens. Hence it may invade both 
surfaces of the lens uniformly ; or it may commence at the 



CORTICAL CATARACT. 339 

middle, or, which is more common, at the circumference, in the 
form of small, greyish-white streaks, or radii, running towards 
the centre, the intermediate lens substance being at first 
transparent, or but slightly opaque. Shortly, however, a 
general opacity sets in, which may, or may not, render the 
striae invisible. Sometimes the stellate figure may be observed 
in both the anterior and posterior cortical portion of the lens, 
the remainder being transparent, or slightly dotted with opaque 
points. This condition is easily recognized by lateral 
illumination, the anterior streaks appearing just behind the 
pupil, and the posterior further back, and having a concave or 
meridional appearance. These appearances are especially 
marked through the opthalmoscope, the spots and stripes 
being projected in dark, well-defined opacities on the red 
surface of the fundus. Unlike lamellar cataract, its progress 
is usually rapid, particularly in children, in whom it often 
matures in the course of a few weeks or months. At a later 
period its rate of increase may be comparatively slow, 
especially if the opacities are small and scattered. 

Total or mature cortical cataracts are of a grey or bluish- 
white tint, the color being most intense at the centre, in 
consequence of the increased density at that point. The 
stellate rays are broad, white, and sometimes slightly glistening. 
If the cataract developes quickly, the lens swells so as to push 
forward the pupillary margin of the iris, which is frequently 
more or less dilated and sluggish. Viewed obliquely, we 
discover that the more superficial layers of the cortical portion 
of the lens are less dense than the central, proving that, 
although soft, this is not a fluid cataract. In the latter the 
white opacity is equally as dense at the periphery as at the 
centre. It is of a milky-white or greyish color, devoid of 
striae, and extends quite up to the capsule, the interior of 
which is sometimes dotted with minute white opacities. 

The consistency of cortical cataract, which is always soft, 



3 40 PRACTICE OF MKDICINE. 

is in infancy and childhood almost fluid. It increases in 
density up to the age of thirty or thirty-five, when the nucleus 
loses to a greater or less extent its soft, pulpy character, and 
becomes somewhat hard. In the course of time, secondary 
changes may set in, disintegration and absorption of the 
affected portions of the lens taking place, causing the latter to 
contract, and the capsule to become more or less wrinkled. 
After the more fluid parts are absorbed, the shriveled capsube 
generally contains only broken-down lens substance, in the 
form of small, chalky-white chips In children, the process of 
absorption may continue until nearly the whole of the over- 
ripe cataract disappears, leaving only a small, hard, chalky 
layer or disc, which, from its resemblance to a dried seed-shell, 
is called by the old writers "siliquose" cataract, (cataracta 
siliqaata). After the age of twenty-five or thirty, the nucleus 
becomes sufficiently hard to resist these secondary changes, 
and the softening is chiefly confined to the cortical substance. 
As soon as the latter becomes fluid, the hard nucleus sinks 

down in it, and thus is formed the so-called "Morgagnian" 

i 
cataract. 



2.-HABD CATABACT. 

NUCLEAR OR SENILE CATARACT. 

As the name indicates, this form of cataract is characterized 
by the presence of a comparatively hard nucleus. It is 
appropriately called "senile," as the change that produces it 
never begins to take place until after the age of from thirty to 
thirty-five, when the nuclear portion of the lens becomes 
harder, and assumes a yellowish tint. The consolidation of 
the nucleus, which takes place gradually, is at first a purely 
physiological process, and may exist for years without any 
deterioration of sight. It is only when vision becomes 



HARD CATARACT. 341 

perceptibly impaired in consequence of a certain increased 
density and opacity of the lens, that the process should be 
regarded as pathological, although the distinction between the 
two forms of hardness and opacity is merely one of degree. 
When this stage is reached, the nucleus exhibits a more or less 
greyish-yellow or brownish-yellow color, quite distinct in 
appearance from the cortical portion of the lens, which at first 
retains its normal transparency, except in the immediate 
vicinity of the nucleus, where perhaps a so-called "arcus senilis 
of the lens" occurs. Subsequently the cortical portion also 
becomes affected, constituting what is called "mixed" cataract. 

If we view nuclear cataract by lateral illumination, it will 
appear as a yellowish, or more rarely as a brownish or black 
opacity, somewhat distant from the pupil, the latter, owing to 
the transparency of the cortical substance, often throwing a 
shadow upon the surface of the opacity. Brown and "black" 
cataracts are due to the absorption of hematine from the 
aqueous humor. These forms are liable to be overlooked, on 
account of the dark color of the pupil, unless the examination 
is made with the ophthalmoscope or by lateral illumination. 

Hard cataract at its commencement presents a stellate 
appearance very similar to that of the cortical variety already 
described ; the opaque streaks being arranged in the form of 
radii, with clear portions of the lens between them. The 
opacity generally begins at the periphery, and may be confined 
to either surface of the lens, or may embrace both. The 
central portion, as well as the spaces between the rays, may 
remain for some time sufficiently transparent for the details of 
the fundus to be seen ; but the opacity gradually extends 
towards the centre of the lens, the intermediate spaces become 
more and more clouded, and finally the entire lens becomes 
affected. 

Senile cataract occurs most frequently after the age of 
fifty, and is apt, sooner or later, to affect both eyes. Its 



342 PRACTICE OF MEDICINE. 

progress is sometimes slow, at others rapid. In its earlier 
stages, it often remains for a long time almost stationary, and 
then advances with great rapidity, reaching maturity perhaps 
within a few weeks. It is generally more rapid the larger, 
broader, and more numerous are the opaque spots and 
stripes. Relatively, its progress is far more rapid in the 
cortical substance than in the nucleus. 

The secondary changes that sometimes occur in senile 
cataract, are similar to those that take place in the cortical 
variety, the chief difference being that the retrograde metamor- 
phosis is confined to the cortex. Partial absorption takes 
place, and scattered chalk-like spots are formed, usually at the 
expense of the cortical substance, which diminishes somewhat 
the thickness of the cataract. These collect into small masses, 
and become attached to the inner surface of the capsule, which 
sometimes appears like a thin veil streched over the hardened 
nucleus and strewn with white granules. The softening of 
the cortex may give rise to the so-called "Morgagnian" cataract, 
as mentioned under the previous head. 

The impairment of vision is frequently much less than the 
degree of opacity would lead us to suspect. This arises in 
some cases from the cloudiness being confined to the portion of 
lens usually covered by the iris. The opacity being the same, 
the clearness depends upon the nearness of the object, the 
degree to which it is illuminated, and the amount of diffuse 
light that is allowed to enter the eye. Hence, if the opacity 
is chiefly limited to the centre of the lens, the patient will see 
best when the diffuse light is cut off, and the pupil dilated ; 
but if confined to the margin, the reverse will occur ; he will 
see best in a bright light, and with a contracted pupil. 



DISEASES OF THE EYE. 343 



3.-CAPSULAE CATARACT. 

We have already alluded to the fact that; during the 
secondary changes which take place in lenticular cataract, the 
fluid and fatty elements become absorbed, and the harder 
portions become attached to the inner side of the capsule, thus 
rendering the latter apparently more or less opaque. But 
since these white, chalky appearances are not situated in the 
capsule itself, it is evident that the term "capsular" cataract 
is not, strictly speaking, correct. This does not, it is true, 
disprove the possibility of the capsule becoming cloudy, but so 
far it has not been observed. Indeed, it is almost certain that 
capsular cataract never occurs except as a complication of a 
previous opacity of the lens ; the deposit being intra-capsular, 
and depending on the condition of the lens substance. In 
making this statement we do not lose sight of the fact, that, in 
certain cases, the hyaline membrane undergoes a sort of 
hypertrophy, or is apparently thickened by a deposit of trans- 
parent layers, which may subsequently degenerate and become 
opaque ; but as a general rule the capsule itself retains its 
transparency. {Stellwag.) 

By capsular cataract, therefore, we understand an opacity 
of the capsule, generally due to opaque deposits upon its inner 
surface, consisting mainly of chalky incrustations, or fragments 
of cholesterine crystals, the capsule being somewhat wrinkled, 
and perhaps thinned. The opacity is seated chiefly behind 
the pupil, sometimes on the posterior half, but generally on 
both halves of the capsule. Sometimes it consists in a simple 
thickening and cloudiness of the capsule, dotted here and there 
with small, chalky masses ; but in most cases the chalky 
opacities predominate, and form a more or less complete 
incrustation on the inner wall of the capsule. 

"Central" capsular cataract is sometimes congenital, but in 



344 Practice of medicine, 

most cases it is the result of an iritis, or of a perforating ulcer 
of the cornea. When the latter is situated near the centre of 
the cornea, the lymph effused in the ulcer comes in contact 
with the corresponding portion of the capsule, in consequence 
of the lens falling forward upon the cornea during the escape 
of the aqueous humor, and a portion of the lymph adheres to 
the capsule after the lens recedes from the cornea. This 
interferes with the nutrition of the subjacent tissues, and the 
latter become more or less cloudy and opaque. These 
finally undergo the usual secondary changes, shrinking greatly, 
and forming a cartilaginous, or more frequently a chalky 
nodule, attached to the inner surface of the anterior capsule, and 
imbedded, so to speak, in the surface of the lens. Sometimes 
the cataractous nodule, instead of being rounded, is of an 
irregular pyramidal shape, the apex projecting above the 
surface of the capsule, and the base slightly imbedded in the 
cortical portion of the lens. This form is called "pyramidal" 
cataract. 

Capsular opacities occurring at the posterior pole of the 
lens, and hence termed "posterior polar" cataract, are some- 
times caused by changes in the contiguous cortical substance 
of the crystalline, or by deposits upon the internal surface of 
the capsule, which take place in the manner already described. 
But posterior polar cataract may also be due to inflammatory 
or nutritive changes in the anterior portion of the vitreous 
humor. These are distinguished by their smooth and shining 
aspect, whereas the former are usually rough and granular. 
They are generally dependent upon chronic inflammation of 
the deeper tissues of the eye, being frequently met with after 
certain forms of choroiditis and retinitis. 



DISEASES OF THE EYE. 345 



4 -TRAUMATIC CATARACT, 

We shall devote this section chiefly to the etiology of 
cataract, beginning with the traumatic, Of the numerous 
causes that give rise to its various forms, wounds and injuries 
of the lens and its appendages are among the most important. 

The opacity generally commences within a few hours after 
the receipt of the injury. If the latter is slight, such for 
example as a very fine puncture that does not penetrate 
deeply, it may cause only a superficial cloudiness in the vicinity 
of the wound, which may disappear, and leave no permanent 
opacity ; but more frequently, the parts surrounding the wound 
swell up, and if much aqueous humor is admitted, the whole 
lens may enlarge, causing the wound in the capsule to gape ; 
and if under these circumstances a portion of the cataractous 
substance protrudes and becomes absorbed, the edges of the 
wound may retract, so as to become cemented together by the 
disintegrated remains of the cataract, and thus give rise to a 
secondary traumatic cataract. Moreover, the swelling of the 
lens may cause it to press injuriously upon the ciliary body 
and iris, and thus lead, perhaps, to irido-cyclitis ; and if the 
iris is badly lacerated, or if it becomes attached to the corneal 
wound, it may even excite a general irido-choroiditis, with its 
attendant consequences. The danger of secondary inflamma- 
tion is considerably less in children than in adults, in conse- 
quence of absorption being more rapid and the injurious 
influences of shorter duration. But no such differences exist 
in cases where the injury was caused by a foreign body, such 
as a bit of percussion cap, which still remains in the eye. 
Here the danger of destructive inflammation is always very 
great. In such cases the surgeon should not fail to keep a 
careful watch over the eye, and promptly adopt such measures 
for its safety, and for that of its companion, as the exigencies 



34^ PRACTICE OF MEDICINE. 

of the case may require. See Glaucoma, Sympathetic 
Ophthalmia, etc. 

Traumatic cataract may also result from a blow or fall, 
which may or may not rupture the capsule of the lens, or 
destroy the continuity of the ciliary processes. If the 
rupture is partial or incomplete, it may escape detection for 
years. A careful examination, however, will generally result 
in discovering the mobility, oblique position, or sinking of the 
lens, the tremulousness of the iris, etc. If the lens has become 
completely dislocated, it may be forced into the anterior 
chamber, between the iris and cornea, where, inclosed in its 
capsule, it may remain for years without exciting any particular 
inconvenience, though this is not generally the case ; or it may 
be driven into the vitreous, where severe inflammation of the 
internal tunics quickly occurs. Spontaneous and congenital 
dislocations also occur ; and although the luxated lens may 
remain transparent for years, it finally becomes cataractous. 

Cataract has also been caused by entozoa perforating the 
capsule and entering the lens. The monostoma lentis, the 
filaria and distoma oculi humani, and the cystercercus, have all 
been found in the crystalline lens. 

Raphania, or ergotism, is an occasional cause of cataract. 
The opacity developes slowly ; and as it generally affects the 
young, the cataract is usually soft. The same is true of 
diabetes, which is a very common cause of cataract. 

Finally, while it most frequently results from the faulty 
nutrition incident to old age, cataract is often both hereditary 
and congenital, (cataracta adnata). The immediate cause in 
these cases according to Stellwag, is supposed to be, "a faulty 
development of the lens, which prevents the elements from 
long maintaining themselves at the height of evolution, and 
causes their premature destruction ; a proceeding that is 
analogous to the early fall of the hair and decay of the teeth." 



DISEASES OF THE EYE. 347 

TREATMENT OF CATARACT. 

Whilst we are free to admit that the vast majority of 
cataracts, especially the hard, can only be removed by 
operative procedures, we see no reason to change the opinion 
we have already expressed, namely, "that incipient cataract 
has in some instances unquestionably yielded to homoeopathic 
medication."* Even Stellwag, looking at the subject from the 
Old School standpoint, says that "medical treatment may be 
of service in so far as it is suited to remove direct or indirect 
causes of cataract"; and adds, "it can scarcely be denied, that 
with the removal of the cause, the development of the cataract 
may be easily impeded, and its progress restricted. But if 
this succeeds," he says, "it is evidently possible that the already 
cloudy portion may be caused to disappear by regressive 
metamorphosis and absorption, and a relative cure thus brought 
about." *f- He also admits that "several creditable authors," 
meaning Tavigno, Arlt, Faye, Himly, and others, "say they 
have seen existing cataractous opacities clear up under the 
systematic use of mercury, after frictions of iodide of potassium 
ointment about the eyes, after the internal and external use of 
Phosphorus, etc., etc." * Such admissions, coming as they do 
from such high authority in the old school, if they do not serve 
to convince, ought at least to render less positive the opinions 
of those of our own school who not only still cling to the old 
notion of the incurability of cataract, but who even claim it to 
be impossible, under any circumstances, to cure — what ? senile 
Cataract ? no, but even "incipient" cataract, by therapeutic 
means. -|* Besides, it cannot be denied that a large 
number of such cases are to be found in our literature, and 
that some of them are vouched for by several of our most 



*See Preliminary Observations. 

t u Treat. on Dis. of the Eye," Fourth Am. Ed., 1873, p. 624. 

Loc. cit. 

+See ' Medical Advance," vol. iv, p. 249. 



348 PRACTICE OF MEDICINE. 

distinguished authors, including such names as Kafka, Quadry, 
Kirsch, Lilienthal, and others of equal note. We are, 
therefore compelled to admit that, under some circumstances, 
cataract is curable, or else of impeaching the integrity and skill 
of some of the most noted and reliable authorities of both 
the allopathic and homoeopathic schools of medicine.* 

But in order to succeed by medical treatment alone, it is 
requisite that the cataract should be of a favorable character, 
that the remedy should be rightly selected, and that its 
administration should be neither irregular nor transient. No 
one would expect to effect a cure by internal treatment after 
degeneration of the lens fibres had occurred ; nor, supposing 
the case to be a proper one, and the remedy to be rightly 
selected, would he look for a permanent and radical change 
under several months. In all ordinary cases, therefore, we 
shall be obliged to resort to operative measures ; but in 
complicated cases, or those attended by circumstances contra- 
indicating an operation, which are by no means rare, we should 
give the patient the benefit of our improved system of practice, 
and not, from any preconceived notions of its inefficiency, 
deprive him perhaps of the only possible means of recovery. 
Our chief difficulty will consist in selecting the proper remedy. 
Aside from the pathological condition of the lens, we shall be 
obliged to fall back upon the symptoms arising from complica- 
tions, if any, or from the state of the patients health, especially 
as regards any abnormal action of the heart, kidneys, or uterus, 
or any other derangement which may in any wise affect either 
the circulation or nutrition of the organ of vision. In the 
absence of any such indications, we shall be compelled to 
address our remedies to the pathological condition itself, and 
for this we have no other guide than experience. The 



*See a very able paper on this subject by Prof. Gilchrist, in the thirteenth volume of 
the A merican Observer, p. 449, et seq. 



OPERATIONS FOR CATARACT. 349 

remedies which have hitherto been employed with favorable 
results, and which deserve special attention, are the following ; 
— Amm. c, Bary. c, Calc. c, Cann. s., Caust, Chim. u., Graph., 
Iod., Kali iod., Lyco., Magn. c, Merc, Phos., Physostig., Sec. 
c, Sep., SiL, Sulph. 

OPERATIONS FOR CATARACT. 

Before proceeding to describe the various methods now 
practiced for the removal of cataract by operation, we shall 
briefly point out some of the principal circumstances and 
conditions which may render it necessary or advisable 
to either defer the operation, or abandon it altogether. 

I. The most favorable cataract for operation is one that 
has just reached maturity ; that is, the cataract is ripe without 
being over-ripe. These terms are altogether relative. A cat- 
aract is ripe for operation when the connection between the 
cortex and nucleus of the lens is stronger or more intimate 
than it is between the cortical substance and capsule. For, if 
only the external layers of the lens are in a soft or fluid con- 
dition, there can be no difficulty in removing the nucleus. 
Nor can there be any great danger incurred, even if the cortical 
layer is of normal consistency, provided the nucleus has ac- 
quired such a degree of density as to readily prevent its sepa- 
ration from the cortex, for then the latter may be safely de- 
tached from the capsule. But if the superficial layers, without 
being abnormally hard, have lost their transparency, and have 
become intimately attached to the capsule, their separation can 
only be effected by violent, and therefore dangerous means. 
Hence such cataracts are said to be unripe for operation. For, 
if any portion of the cortex remains in the capsule, it not only 
swells up and irritates the iris, but is liable to proliferate, giv- 
ing rise to a secondary cataract, if not to destructive inflamma- 
tion of the eye. 



350 PRACTICE OF MEDICINE. 

But a cataract may be over ripe ; that is, the lens may- 
have undergone such retrogressive changes that the cortical 
substance is either broken down into a creamy or chalky fluid 
or pulp, filled with minute sand-like grains, or transformed to a 
dry, cretaceous substance, portions of which are liable to re- 
main in the eye, and thus render the operation extremely dan- 
gerous. 

2. Authorities differ as to the propriety of operating in 
monocular cataract. All agree, however, that the operation 
should not be undertaken unless a favorable result is almost 
certain. The advantages, in case of success, are, first, the im- 
provement in the personal appearance of the patient ; second, 
the enlargement of the field of vision ; and, third, the preser- 
vation of vision in case the other eye becomes cataractous. 
On the other hand, in case of failure, if the inflammation ex- 
cited by the operation should continue for a long period, or 
until the other eye has become affected, the patient would be 
deprived during this period of any service from the sound eye ; 
there is also the danger of the latter becoming sympathetically 
inflamed. 

3. Surgeons also differ as to whether, in binocular cata- 
ract, only one eye at a time should be operated on, or both at 
once. Our practice has been to operate on one eye at a time, 
and not to touch the other until the first has recovered ; thus 
lessening the danger of inflammation, diminishing the shock to 
the system, avoiding the risk of any sympathetic influence of 
one eye upon the other, and furnishing an opportunity to dis- 
cover any constitutional peculiarity or unfavorable tendency, a 
knowledge of which would be of service in the subsequent 
management of the case. Of course, if only one cataract is 
ripe, there is no occasion to wait for the other to mature ; but, 
if circumstances are favorable, we should promptly operate 
upon the former, so as to enable the patient to follow his usual 
avocations whilst the other is maturing. 



OPERATIONS FOR CATARACT. 351 

4. It is highly important not to operate unless the eye is 
in an otherwise healthy condition. The chief exception to this 
rule is where an inflammation is kept up by a swollen or dislo- 
cated lens, and then the urgency will depend upon the charac- 
ter of the inflammation. Nor would it be safe to operate on 
an eye that had recently been in a state of inflammation, 
though chronic inflammation of the surrounding parts some- 
times forms an exception. 

5. It is also important that the state of the patient's 
health should be such as to favor an operation, or at least such 
as not to endanger the result. Hence the various cachexia, 
such as scrofula, tuberculosis, syphilis, etc., as well as any other 
condition, whether physical or mental, which greatly depresses 
the vital powers, is to be regarded as endangering, and, to a 
corresponding extent, contra-indicating an operation. It is es- 
pecially important to determine whether the patient is suffering 
from diabetes, as this is a very frequent cause of cataract, and 
the lens does not generally become affected until late in the 
disease, when the health is seriously impaired. If diabetes is 
found to exist, we should be careful to ascertain whether there 
is any co- existing affection of the retina or optic nerve, as this 
would render the prognosis very unfavorable. 

6. The season of the year is of but little consequence, 
provided we avoid thermometrical extremes, and these chiefly 
on account of their interfering with the comfort or exercise of 
the pat'ent. Thus, in very hot weather the patient is apt to be 
restless, and confinement in bed is much more difficult ; be- 
sides, wounds rarely heal as readily in July and August as they 
do in cooler months. On the other hand, very cold weather is 
not only unfavorable for regular exercise prior to the operation, 
but, by confining the patient to his room longer than is neces- 
sary, often greatly protracts convalescence. 



352 



PRACTICE OF MEDICINE. 



1.-DISCISSI0N. 



DIVISION OR SOLUTION OF CATARACT. 

This operation is indicated in the cortical cataract of child- 
hood, in certain forms of lamellar cataract, and in opacities of 
the posterior capsule, especially such as result from linear or 
flap extraction. 

The operation consists in simply dividing or lacerating the 
anterior capsule with a fine needle, so as to break up the cata- 
ract and facilitate its absorption in the aqueous and vitreous 
humors. It may be performed either through the cornea (kerat- 
onyxis) or through the sclerotica (sclerotonyxis). The latter 
is generally done with a Beer's, or spear-pointed cataract needle. 
(PI. I., Fig. 10) ; but the former requires a round stop-needle — 
that is, one the diameter of whose shaft gradually increases as 
it recedes from the point, in order to prevent the escape of the 
aqueous humor. 

If the operation by scleroto- 
nyxis is selected (Fig. 14, a.), 
after dilating the pupil with 
Atropine, separating the lids 
by a stop-speculum (PI. IL, Fig. 
33), or by the fingers of an as- 
sistant, who also steadies the 
globe with a double hook (PI. 
I., Fig. 6), or, what is better, a 
pair of fixing forceps (PL IL, 
Figs. 36, 37), fastened to the 
lower part of the ocular con- 
junctiva, unless the eye can be 
fully controlled by the fingers, the operator enters the needle 
perpendicularly on the temporal side of the sclera, about a line 
and a half behind the border of the cornea, and the same dis- 




DISCISSION. 



discission. 353 

tance below the horizontal diameter of the eye, the cutting 
edges of the needle being directed antero-posteriorly, in order 
to lessen, as much as possible, the danger of wounding any of 
the larger vessels of the choroid. The point of the needle is 
then pushed forward, with its side facing the cornea, through 
the periphery of the lens into the anterior chamber, as far as 
the upper and inner margin of the pupil. (See Fig. 14). Then, 
in order to tear away as large a piece of the anterior capsule 
as possible, and force it into the vitreous humor, where it will 
create the least amount of irritation while being absorbed, the 
operator lays the flat side of the needle directly over the center 
of the capsule, and presses it slowly backwards towards the 
vitreous. He then brings the needle back into the anterior 
chamber, in order to tear away and break up so much of the 
remaining portions of the capsule and lens as may be deemed 
advisable. In infants and young children, in whom the lens is 
very quickly absorbed, the capsule cannot be too freely divided ; 
but in adults this is not the case, and in order not to cause too 
great a swelling of the lens, or the admission of too many frag- 
ments into the anterior chamber, either of which may give rise 
to severe iritis or irido-cyclitis, it is best not to lacerate the 
capsule too freely at one time, but to repeat the operation at 
intervals of a few weeks, or whenever the process of absorption 
requires to be hastened. 

The operation by keratonyxis (Fig. 14, d) is performed by 
passing the round stop-needle (represented in the cut), instead 
of Beer's, somewhat obliquely through the middle of the upper 
or lower outer quadrant of the cornea, in such a manner as to 
avoid touching the margin of the iris during the division of the 
lens. Care should be taken not to make the track of the wound 
too long by entering the cornea too obliquely, as then the mo- 
tion of the needle in breaking up the cataract would strain and 
bruise the tissue of the cornea, and probably lead to more or 

less corneal opacity. The extent to which the laceration and 

45 



354 PRACTICE Of MEDICINE* 

■ -m 

comminution of the capsule and lens should be Carried, will 
depend chiefly upon the age of the patient. Thus, in infants 
and young children, where, as above intimated, one operation 
may be made to suffice, it should be much more extensive than 
in adults, in whom, for reasons already stated, it would be safer 
to repeat it. 

Very little after-treatment is generally required. The pa- 
tient should remain in a moderately darkened room for a day 
or two, with the eyes lightly bandaged, care being taken to 
keep the iris well out of the way of the lens by the instillation 
of Atropine. If the lens should swell greatly, so as to cause 
much irritation, and especially if symptoms of severe inflam- 
mation should set in, the cataract should be immediately re- 
moved by linear extraction. If this is rendered difficult or 
hazardous, in consequence of any considerable portion of the 
lens substance having fallen into the anterior chamber, or for 
any other reason, it will be best to combine an iridectomy with 
it, especially if the inflammation has already given rise to an 
increase of intra-ocular tension, or impairment of vision. 



2.-DEPRESSI0N. 

RECLINATION OR COUCHING. 

This operation, once so common, has deservedly fallen into 
very general disrepute, and ought perhaps to be entirely aban- 
doned. The danger lies in the depressed lens ultimately com- 
ing in contact with the choroid, and exciting a destructive irido- 
choroiditis. Stellwag, however, considers the operation "still 
applicable in cases of a very large sclerosed nucleus, and pro- 
portionately thin but tough cortex." 

Depression may be performed with a curved Scarpa needle 
(PI. I., Figs. 7, 8) or a Pancoast needle (Fig. 9). The prelimi- 



DEPRESSION. 355 

nary steps of the operation are the same as for discission (which 
see). The operator, holding the needle as a pen, with the con- 
vexity upwards, introduces its point exactly in the transverse 
diameter of the globe, and one and a half or two lines behind 
the cornea. The point is first directed inwards toward the 
center of the vitreous, but as it is carried forward it is made to 
appear directly behind the pupil, and in front of the anterior 
capsule. The needle is then gently pressed backwards against 
the cataract, so that the lens may become loosened from the 
zonula, and afterwards, by a half-circular turn, raised above the 
lens, with its convexity upwards. The lens is then pressed 
backwards and downwards out of the line of vision, the needle 
gently rotated to disengage it from the lens, and then lifted a 
little to see if the lens is inclined to rise with it ; if not, the 
operation is finished, and the needle may be withdrawn. But 
if the lens should rise, it must be more completely separated 
from the zonula, or, if the operator piefers, he may rupture the 
posterior capsule with the needle, after which the lens should be 
again depressed. 

Reclination — This is a modification of depression, in which 
the lens, instead of being pushed downwards in a straight direc- 
tion, is turned on its axis, so as to lie horizontally in the vitre- 
ous humor, below the pupil. As it possesses no material advan- 
tages over the operation just described, it is unnecessary to 
dwell upon it. 

The after-treatment for depression is the same as for flap 
extraction (which see). 



356 



PRACTICE OF MEDICINE. 



3 -LINEAR EXTRACTION. 



This operation, which is indicated in both congenital and 
traumatic forms of cataract, when the lens substance is fluid or 
pulpy, is now employed for the immediate removal of the 
latter through a small linear incision. It may also be per- 
formed a few days after the ordinary operation of discission, 
when the lens has become softened and swollen, instead of 
leaving it, or its fragments, to be slowly absorbed by the 
aqueous humor. It is also suited for the removal of siliculose 
and other forms of regressive and secondary cataracts, 
in which the capsule is greatly shrunken, and contains but a 
small portion of degenerated lens substance. 

If the capsule is entire, the operation is performed by first 
dividing the anterior capsule and lens by a very fine curved 
needle, (PL I , Figs. 8, 9), passed through the temporal side 
of the cornea, near its margin, without evacuating the aqueous 
humor. This puncture is then enlarged in a perpendicular 
direction, to the extent of about two lines, by a lance-shaped 
knife, or one similar to Fig. 13. The cataract, if fluid, will 
now escape from the opening ; but if pulpy it will have to be 
assisted by the curette, or Daviel's spoon. (PL I., Fig. 31.) 
The operator first presses the spoon against the posterior lip 

of the incision, so as to cause 
it to gap, at the same time 
gently pressing the opposite 
part of the globe with his 
finger ; and if this does not 
succeed in causing the lens 
matter to escape, he endeav- 
ors to effect its dislodgement 
by a circular motion of the 
ends of his fingers upon the 
lids ; but if this also fails, he 



Fig. 15. 




LINEAR EXTRACTION. 



SUCTION OPERATION. 357 

carefully introduces the spoon into the wound, and scoops out 
any remaining portion of the lens substance. (See Fig. 15.) 
If any portions of opaque capsule still remain, they may be 
removed by means of the canula forceps, (PI. I, Fig. 3), or by 
one of the iris hooks, (Figs. 4, 5). Siliculose and other 
forms of secondary cataracts may also be removed in the same 
manner ; but as it is very apt to set up severe and even 
dangerous inflammation, in consequence of coexisting synechias, 
or other complications, most operators now prefer to leave the 
membrane in situ, and to make a small clear aperture in it by 
means of the round stop-needle, as this is found to give 
excellent sight, and is attended with far less risk of exciting 
inflammation. The needle opening may be enlarged, if 
necessary, by means of a pair of canula iris scissors, (PI. I, 
Figs. 1, 2, 18, 19), passed through a linear incision. After 
the operation, the pupil should be kept well dilated with 
Atropine, and a light bandage should be applied to the eyes. 
If inflammation supervenes, it should be subdued by ice-water 
compresses, or other appropriate treatment. 



4.-SUCTI0N OPERATION. 

This is an ancient mode of extracting soft cataract, 
recently revived by Mr. Pridgin Teale. The instruments 
required are a broad needle for puncturing the cornea and 
dividing the anterior capsule, and a suction tube, (PI. II, Fig. 39), 
consisting of a glass stem, (B), five or six inches in length, 
with a silver tubular curette (A) at one end, five-eighths of an 
inch in length, and of the size of an ordinary curette, and an 
exhausting tube, (C), about twelve inches in length, with a 
mouth-piece at the other end. The tubular curette is 
passed through the incision made by the needle, as described 
under the head of linear extraction, and carried through 



358 PRACTICE OF MEDICINE. 

the pupil, previously dilated by Atropine, to the centre 
of the lens substance. Gentle suction is then made upon 
the mouth-piece, and the lens matter is drawn into the 
glass tube, which allows the operator to watch its progress, 
and thus regulate the aspirative efforts. These should be 
continued as long as any opaque matter appears in the pupil, 
the end of the curette being slightly moved about within the 
capsule, so as to take up any portions of the crystalline 
substance which may be observed to remain. If any 
portions of the crystalline are too glutinous or tenacious to 
be readily drawn into the curette, they may be left to dissolve 
in the aqueous humor, as after an ordinary operation for dis- 
cission ; or they may be removed by a subsequent suction 
operation, after having become sufficiently softened, provided 
there has been no rupture of the posterior capsule, nor too 
much irritability of the eye, nor any iritis ; conditions which 
in the opinion of Mr. Teale generally render the operation 
unsuitable. 



5. -FLAP EXTRACTION. 

This operation is most suitable for senile cataracts, but 
may also be employed for the cortical variety, in cases where 
the cortical substance has softened, and the nucleus is large 
and of more than normal consistence. The instruments 
required are : an ordinary cataract knife, such as Beer's (PL I, 
Figs. 28, 29) or White's, (Fig. 23) ; a pair of fixing forceps, 
(PL II, Fig. 36); a cystotome, (Fig. 12), for dividing the capsule ; 
a curette, (Fig. 31), which, for the sake oi convenience, is 
generally attached to the other end of the cystotome ; and a 
blunt-pointed secondary knife, or pair of scissors, for enlarging 
the corneal incision, or what is better, an instrument expressly 
devised for the purpose, represented in PL I, Fig. 20. 



FLAP EXTRACTION. 359 

The patient being in a recumbent position, and the lids 
separated by an experienced assistant, the operator, placing 
himself in a convenient and unrestrained position behind the 
patient, fixes the globe by pinching up a fold of the conjunctiva 
with the forceps, and then enters the cornea with the cataract 
knife about a quarter of a line from its outer edge, and in the 
line of its transverse diameter, taking care that the point of 
the knife enters the anterior chamber, instead of between the 
laminae of the cornea ; he then carries it steadily forward, with 
the blade parallel to the surface of the iris, until its apex 
emerges from the cornea at a point diametrically opposite to 
where it entered, when the forceps are to be laid aside, as the 
globe is now fully under the control of the operator. The 
blade is now carried steadily forward until it cuts its own way 
out ; or, when the section is nearly finished, the operator, 
following the advice of Von Graefe, instead of carrying it 
straight on, may complete the section by drawing it back from 
heel to point, thus diminishing the straining by causing a relax- 
ation in the tension of the muscles of the eye, at a time when 
it would otherwise be at its maximum. The lids are now care- 
fully closed, so as not to cause an eversion of the flap. After 
resting a moment, the eye is again opened, the cystotome care- 
fully introduced, and the capsule freely lacerated, the operator 
being careful, in doing it, not to displace the lens into the vitre- 
ous humor. We have now reached the third and most delicate 
part of the operation, namely, the removal of the lens. This 
will require to be managed with particular care, in order to 
prevent the escape of any considerable quantity of the vitreous, 
an accident that may not only give rise to an insidious form of 
irido-choroiditis, but is likely to be followed by detachment of 
the retina. After the eye is again opened, the operator places 
the points of his index and middle fingers, or the end of the 
curette, against the lid, on the side opposite the incision, and 
the point of the other index finger on the other side of the 



36o 



PRACTICE OF MEDICINE. 




FLAP EXTRACTION. 



globe, so as to exercise a steady but gentle pressure upon it. 

This generally causes the 
lens to advance through the 
pupil into the anteriorcham- 
ber, and to make its exit 
through the incision (see 
Fig. 16) ; if not, we must 
aid it with the curette, un- 
less the hindrance is behind 
the pupil, when we must 
lacerate the capsule again, 
and proceed as before. Af- 
ter resting the eye a few 
seconds, the vision may be 
tested by trying if the patient can count fingers ; and if he 
cannot, we should examine the pupil to see whether any por- 
tions of the lens substance have been stripped off and 
left behind, in which case they should be removed with 
the curette, or with the canula forceps (PL I., Fig. 3). 

After-Treatment. — After the operation the patient 
should be placed in bed in a darkened room, and the bed cover 
fastened above his arms, so as to prevent his touching his eyes 
during sleep. A binocular bandage should be lightly applied, 
and changed whenever it becomes very uncomfortable to the 
patient, The edges of the lids should be kept from sticking 
together, by sponging with luke-warm milk and water, after 
which they should be anointed with a little cosmoline, or cold 
cream, care being taken not to disturb the flap by opening the 
lids unnecessarily, or without due caution. After union of the 
flap occurs, which generally takes place within forty-eight 
hours, or less, after the operation, Atropine should be instilled 
between the lids, without widely separating them, in order to 
dilate the pupil and lessen the danger of secondary cataract. 
If no untoward symptoms occur, the eye should not be opened 



PERIPHERAL LINEAR EXTRACTION. 361 

for several days, as an early or frequent movement is apt to 
induce iritis. But if the eye becomes very hot and painful, it 
should be examined, and if there is no protrusion of the iris, 
nor any marked suppuration of the cornea, cold water com- 
presses should be applied ; but if the iris is prolapsed, a firm 
compress should be at once applied, which will not only pre- 
vent its increase, but will even cause it to shrink. Methodical 
compression is also the best treatment for suppuration of the 
cornea, tending, as Wells truly observes, more than any other 
remedy, to diminish the swelling of the lids and the discharge, 
and to limit the suppuration of the cornea. 

In this country, patients are seldom confined to the bed 
more than two or three days after an operation for extraction. 
In favorable cases a shade is generally substituted for the band- 
age in the course of a week or so, in order that the eye may 
gradually become accustomed to the light. In the case of 
children the bandage is frequently omitted altogether, the pa- 
tient being simply confined to a dark room. 



6.-PERIPHERAL LINEAR EXTRACTION. 

VON GRiEFE'S MODIFIED LINEAR OPERATION. 

The indications are the same as for the ordinary flap ex- 
traction ; and it, or some modification of it, is now very gener- 
ally substituted for that operation. The instruments employed 
are : A Graefe's cataract knife (PI. II., Fig. 34) ; a sharp and a 
blunt hook (Figs. 35 a: ond 35 £); a delicate, sickle-shaped nee- 
dle (PI. I., Fig. 8) ; iris scissors (Figs. 1, 2, 18, 19) ; iris forceps, 
(Fig. 3) ; toothed forceps (PI. II., Fig. 36), and a stop-speculum 

(Fig. 33). 

Very few operators now adhere closely to Von Graefe's 
method of operating. We are in the habit of performing per- 
ipheral extraction in the following manner . The patient hav- 
ing been brought under the influence of an anaesthetic (we 
46 



362 



PRACTICE OF MEDICINE. 



FIG. 17. 



generally prefer a mixture of equal parts of chloroform and 
sulphuric ether), the eyelids separated with the speculum, and 
the eye fixed and somewhat depressed with a pair of fixing 
forceps, as represented in the cut, the point of the knife, with 
its cutting edge upwards, is entered in the sclera, about one- 
third of a line behind the upper and outer edge of the cornea, 
and cautiously pushed downwards and inwards until it pene- 
trates about three lines into the anterior chamber, when the 
point is raised, carried horizontally across the chamber, and 
made to emerge at a point exactly opposite to that of entrance 
(see Fig. 17). 

The edge of the blade is 
now turned somewhat ob- 
liquely forwards, so as to 
complete the section at the 
upper margin of the cornea, 
by pushing the knife for- 
ward until its length is near- 
ly exhausted, and then 
drawing it gently backwards 
toward the point. After 
completing the section of 
the cornea, but before sev- 
ering the conjunctiva, the 
peripheral extraction. edge of the knife is turned 

forwards and somewhat downwards, so as to divide the 
conjunctiva in such a manner as to form a conjunctival 
flap of about a line in breadth. The prolapsed 
iris is then exposed by laying back the little con- 
junctival flap over the cornea, seized with the forceps, 
drawn out to the required extent, and excised close up to its 
ciliary attachment. This requires extreme care, in order to 
prevent any portion of the iris remaining in the wound, which 
would not only excite iritis, but retard cicatrization. We 




PERIPHERAL LINEAR EXTRACTION. 363 

now come to the laceration of the capsule, which should be as 
free as possible. The sickle-shaped needle is passed flat- 
wise through the incision to the opposite side of the pupil, and 
commencing as near as possible to the lower margin of the 
capsule, the incision is carried beneath the iris, as recommended 
by Wells, to the upper border of the capsule ; another incision 
is made in a similar manner through the proximal side of the 
capsule ; and then the upper border is freely lacerated in the 
line of the corneal incision, so as to unite the two former 
incisions. This forms a sort of flap in the anterior capsule, 
which greatly facilitates the escape of the lens. The stop- 
speculum should now be removed, and gentle pressure made 
upon the lower margin of the cornea with the needle or 
curette, when the upper edge of the lens will probably present 
at the section ; if it should not readily escape therefrom, its 
exit may be aided by introducing the two hooks, (PL II, Fig. 35), 
one on each side of the lens, and scooping it out. After the 
lens engages in the section, its removal will be facilitated by 
gentle pressure with the curette upon the lower portion of the 
cornea. If it fails to engage readily, by showing a tendency 
to pass behind the upper lip of the incision, it should be tilted 
forward by making slight pressure above the wound, the edge 
of which should also be pressed backward, so as to cause the 
lens to enter the incision. If portions of the cortical matter 
should remain behind after the nucleus is extracted, they 
should be coaxed forward by gently rubbing the lids in a cir- 
cular manner with the ends of the fingers. 

After Treatment. — This is the same as that for flap 
extraction, except that after the first two or three days, if no 
unfavorable symptoms occur, the patient may be allowed much 
greater freedom. Atropine should be instilled as early as 
the second day after the operation. If inflammatory compli- 
cations occur, the case should be managed as directed under 
flap extraction, (which see). 



364 PRACTICE OF MLDICINE. 

DIV. V.— OPTICAL AIDS AND TESTS. 

Before enterning upon the description of the anomalies of 
refraction, accommodation, and other functional disturbances 
of the eye, it will be best to devote a few paragraphs to the 
consideration of some of the more important of the optical 
aids and tests relating to their discovery and correction. 

l.-THE OPHTHALMOSCOPE. 

The reason that the pupil of a healthy eye usually appears 
black, is not because all the rays of light that enter it are 
absorbed, for some of them are always reflected, but because 
the reflected rays, instead of returning to the eye of the 
observer, are, in consequence of the refractive power 
of the dioptric media, reflected back to exactly the 
point from whence they came ; that is, the incident and 
reflected rays exactly coincide. In order, therefore, that the 
eye of the observer should catch the returning rays, it must be 
placed between the source of light and the eye under examina- 
tion, and this, in consequence of the interposition of the observer, 
cannot be done without intercepting the illuminating rays. 
Moreover, it must be remembered that the examiner will be 
unable to perceive light emanating from the eye of another 
person, when the latter is exactly accommodated for the eye of 
the observer, since only a dark image will be formed on the 
retina of the eye under examination, and hence only a reflection 
of this dark portion of the retina can be returned to the eye 
of the observer. 

In order, therefore, that the interior of the eye may be 
distinctly seen, it is necessary (1) that it be sufficiently illumin- 
ated ; (2) that the eye of the observer be situated in the 
direction of .the reflected or emergent rays ; and (3) that these 
rays, which are convergent, be rendered divergent or parallel. 



THE OPHTHALMOSCOPE. 365 

Now, Prof. Helmholtz found that all this could be accomplished 
by simply allowing the light of a lamp to fall. on a polished 
plate of glass, in such a manner as to reflect the rays into the 
eye to be examined, and then, after having made the con- 
vergent rays divergent by means of a concave lens, placing 
himself on the other side of the glass plate, so as to catch the 
emergent rays as they passed through it. But this, the first 
and simplest form of the ophthalmoscope, is now seldom 
employed ; highly polished mirrors, which possess much 
greater illuminating power, having been substituted for the 
glass plate. These mirrors are provided with a small aperture 
in the centre through which the returning rays reach the eye of 
the observer. 

As our object is merely to illustrate the principle of its 
action, and not to describe with particularity the various forms 
of the instrument, we will simply add, that ophthalmoscopes, 
as now constructed, may be divided into four different classes. 
I. The portable or hand opthalmoscope, of which we have 
three distinct forms, namely, (a) Liebreich's, which consists of 
a slightly concave metallic mirror, attached to a convenient 
handle, and provided with a small bracket or clip for holding 
a convex or concave lens; (b) the ophthalmoscope of Coccius, 
which consists of a plane mirror combined with a double 
convex collecting lens ; and (c) the ophthalmoscope of 
Zehender, which differs from that of Coccius in being provided 
with a slightly convex mirror, instead of a plane one. 2. The 
fixed ophthalmoscopes, which are especially suited for class 
demonstrations, as their successful use does not depend on the 
dexterity of the observer. 3. The binocular ophthalmoscopes, 
by which we are enabled to use both eyes at once, and thus, 
by obtaining a stereoscopic view of the fundus, readily distin- 
guish any change of surface on the retina and optic disc. 
4. The aut-ophthalmoscope, by which the observer is enabled 
to examine the interior of his own eye. Of these, the most 



366 PRACTICE OF MEDICINE. 

useful for the general practitioner is the ophthalmoscope of 
Coccius, which possesses the following advantages over that of 
Liebreich, which is the one in most common use : — first, we 
can more fully concentrate the light upon any given part of 
the fundus ; secondly, we can readily increase or diminish the 
focal distance and illuminating power of the mirror ; thirdly, 
we can generally obtain a much better view of the fundus 
through a contracted or natural sized pupil, in consequence of 
the corneal reflex being considerably less ; and, fourthly, it is 
far better adapted for the direct method of examination. 

MANNER OF USING THE OPHTHALMOSCOPE. 

I. Indirect Method. — The examination of the inverted 
image, or the indirect method, as it is called, is conducted by 
seating the patient in a darkened room, with a lamp placed by 
the side of and a little behind the eye to be examined. The 
surgeon then seats himself in front of the patient, and holding 
the ophthalmoscope in his right hand, places the aperture of 
the mirror close to his eye, directing the instrument in such a 
manner as to cast the reflection of the flame directly into the 
pupil. To be able to do this with facility, and at the same 
time keep the eye well illuminated while conducting the exam- 
ination, requires considerable care and experience, as the slight- 
est movement of the mirror is liable to throw the reflection far 
away from the pupil. Having illuminated the eye, the surgeon 
takes the rim of the object lens between the forefinger and 
thumb of his left hand, and holding the lens from two to three 
inches from the patient's eye, according to its focal length, at 
the same time steadying the hand by placing one of his fingers 
upon the edge of the orbit, he endeavors to obtain an ophthal- 
moscopic view of the fundus. This is somewhat difficult for 
the beginner, who is apt while adjusting the lens to displace 
the mirror ; and it is not until he learns to use the hands inde- 
pendently of each other that he can make a proper examina- 



MANNER OF USING THE OPHTHALMOSCOPE. 367 

tion of the eye. He then finds that the rays of light reflected 
from the fundus, after passing thrnugh the lens, form an in- 
verted image. If the eye of the observer is presbyopic or 
hypermetropic, the image is rendered more distinct by using a 
convex glass in the clip behind the mirror. The same is true 
if the eye of the patient is hypermetropic. If the observer 
wishes to gain a view of the optic disc, he should direct the 
patient to look toward his (the surgeon's) right ear, if the right 
eye is under examination, and vice versa, in order that the axis 
of vision may be turned slightly inwards, so as to bring the 
optic nerve entrance directly behind the pupil. If the patient 
looks straight forwards, the surgeon will see the region of the 
macula lutea, which is distinguished by being of a slightly 
darker color than the rest of the fundus, and without any ap- 
pearance of blood-vessels passing over it. The ophthal- 
moscopic appearance of the optic papilla has already been 
given (see Fig. 10). The color of the fundus of the normal 
eye differs according to the complexion of the individual. In 
light-complexioned persons it is light or yellowish-red, while in 
persons of dark complexion it is dark red. 

2. Direct Method. — If the examination be made without 
the lens in the left hand, the image will be erect and much 
larger than when made by the indirect method As perfect 
relaxation of the accommodation is required in order to render 
the emergent rays parallel, and as this is difficult to obtain 
without the use of Atropine, in consequence of the close ap- 
proximation of the patient to the observer leading him, not- 
withstanding he is directed to look at some distant object, to 
accommodate for a much nearer point, it is advisable to dilate 
the pupil with Atropine, as this secures at once the needed re- 
laxation, and at the same time increases the size of the field 
of vision, and also facilitates the illumination of the fundus. 
The lamp should be placed on the side and a little behind the 
plane of the eye under examination, the surgeon seating him- 
self on the same side and examining with the corresponding 



368 PRACTICE OF MEDICINE. 

eye — that is, using the right eye for the right eye of the pa- 
tient, and vice versa. If the image is indistinct, either in con- 
sequence of the surgeon being unable to fully relax his own 
accommodation, or in consequence of his eye or that of the 
patient being myopic, he will find it necessary to use a concave 
lens in order to render the rays parallel. But, if the eye of 
one is myopic, while that of the other is hypermetropic, the 
difference in the refractive power of the two eyes may be so 
far neutralized as to enable the surgeon, by using his accom- 
modation, to examine without the aid of a concave lens. As 
every ophthalmoscope is supplied with a series of these lenses, 
of different focal lengths, fitting into the bracket or clip behind 
the mirror, the surgeon will have no difficulty in selecting one 
to suit the condition of his own and the patient's eyes, whether 
emmetropic, myopic or hypermetropic. 

The advantages afforded by the direct method of examina- 
tion are (i) that we are enabled to ascertain the optical condition 
of the eye independent of its visual power, or of the statements 
of the patient ; and (2) that we are enabled to measure defi- 
nitely the amount of elevation or depression of any portion of 
the fundus ; such, for example, as the amount of excavation of 
the optic disc, the height of tumors, the amount of swelling in 
the retina, etc. On the other hand, the field of vision is more 
limited, and the examination more difficult, than by the indi- 
rect method, the employment of which renders all nice dis- 
tinctions as to myopia, hypermetropia, and the state of the 
accommodation unnecessary — conditions which must always be 
taken into the account in searching for the retinal image by the 
direct method. 

2.-LATEEAL OR OBLiaUE ILLUMINATION. 

This method of exploring the anterior and central por- 
tions of the globe is best conducted in a darkened room. The 
light is placed in the same position with respect to the patient's 



SPECTACLES. 369 

head as in the ophthalmoscopic examination. A double con- 
vex lens is then. held between the lamp and the eye to be ex- 
amined, in such a manner as to concentrate the light upon any 
portion of the cornea, iris, crystalline lens, or vitreous, that the 
surgeon desires to illuminate. We may obtain a magnified 
image of these parts, and thus give greater clearness to the de- 
tails, by holding a second bi-convex lens immediately in front 
of the eye — that is, directly between the patient's eye and our 
own. In this manner we may detect slight opacities or irregu- 
larities in the cornea which would otherwise escape notice, ex- 
amine minutely the texture and condition of the iris, discover 
the faintest traces of cataract, or the presence of foreign bodies 
in the anterior chamber, observe various morbid changes in the 
vitreous, hemorrhagic effusions, floating opacities, etc., and, in 
some cases, the projecting folds of a detached retina. It 
will thus be seen that lateral illumination is oftentimes no mean 
substitute for the ophthalmoscope, while the ease and rapidity 
with which it may be employed renders it doubly valuable as 
a means of detecting many diseased conditions. A good rule, 
therefore, and one that is generally observed in practice, is to 
begin the examination with oblique illumination, and, if there 
is any remaining obscurity about the case, to clear up the diag- 
nosis with the ophthalmoscope. 

3-SPECTACLES. 

These are generally employed for the purpose of correct- 
ing such optical defects as cannot otherwise be rectified. They 
consist of convex spherical lenses for the correction of hyper- 
metropia, concave spherical for myopia, cylindrical for astigma- 
tism, and a combination of both spherical and cylindrical for 
complicated forms of ametropia. Besides these we have the 
following special forms and combinations : 

Pantoscopic Spectacles \ termed by the French verres a double 
47 



370 Practice of medicine. 

foyer, consist of lenses the upper and lower half of which have 
different foci. They are especially useful where the presbyopia 
is combined with myopia or hypermetropia. In the former 
case the upper half should be concave to neutralize the myopia, 
and the lower half convex to neutralize the presbyopia. 

Periscopic Spectacles, consisting of concavo-convex glasses, 
are constructed for the purpose of reducing the spherical aber- 
ration to a minimum. When the concave surface is towards 
the eye, the image is less distorted, on account of there being 
less irregular refraction at the periphery of the lenses ; conse- 
quently, the observer is enabled to look more obliquely through 
them. 

Prismatic Spectacles, the glasses of which are ground either 
in the form of prisms, or of prisms and lenses combined, are 
used for relieving or strengthening certain muscles of the globe. 
The bases of the prisms are generally turned inwards, for the 
purpose of relieving the internal recti muscles. (See Muscular 
Asthenopia). The same object may be accomplished by what 
are called decentered lenses. These are so constructed as to 
throw the centre a little to the inner side of the visual axis in 
convex lenses, and to the outer side in concave glasses, thus 
producing a slight prismatic effect. 

Cataract Spectacles consist of convex lenses of great 
refractive power. The eye having lost the power of accom- 
modation, two sets will be required, one for near objects, of 
about two and a half inches focal length, and the other of 
about four and a half inch focus for distant objects. The 
glasses should be small, as large ones, by admitting too much 
light, generally cause more or less dazzling. They are, of 
course, adapted to every form of aphakia. 

Stenopaic Spectacles are constructed for the purpose ot 
excluding the peripheral, and permitting only the central rays 
of light to enter the eye. For this purpose, metallic plates 
with small central apertures are used in place of glasses. 
They increase the sharpness of vision for near objects, and are 



TEST TYPES. 37 1 

also useful in opacity of the cornea, but as they contract the 
field of vision, they are not adapted for distant objects. 

Protective Spectacles, or eye protectors, are composed of 
variously colored glasses, amber, brown, grey, blue, green, etc. 
The majority of ophthalmologists recommend blue glasses, as 
these exclude the orange rays, which are the most irritating to 
the retina ; but Dr. Dobrowolski, of St. Petersburg, gives the 
preference to grey or smoke-colored glasses. He argues that 
in attempting to shield the eyes from too bright a light, we 
should employ glasses which will diminish equally all the rays 
which constitute sun-light, and not confine the patient to blue 
glasses, which only exclude the yellow rays, nor to green ones, 
which only protect the eye from the red rays, but should use 
the grey or smoked glasses, which not only diminish the 
passage of all the rays, but also enable the eye to readily 
accommodate itself again to ordinary sunlight, a matter of 
some difficulty after wearing the blue spectacles.* 

The most convenient instrument for ascertaining the focal 
strength of lenses, is formed on the model of the ordinary 
measuring stick used by shoemakers. The stationary upright, 
or toe piece, is fitted to receive the lens, and the movable 
upright, or heel piece, has attached to it a card on which are 
small printed letters. Placing the card at the focal distance 
required, the power of glasses is readily ascertained by chang- 
ing the lenses until a suitable one is found, or by selecting 
another lens which, placed before the first, will render the 
letters distinct, and then adding or subtracting its power. 

4.-TEST TYPES. 

In order to have some generally accepted standard by 
which the range and acuteness of vision may be readily ascer- 
tained, and referred to in published cases, Prof. Jaeger, Dr. 



Am. Horn. Obs., vol. xi, p. 555. 



372 PRACTICE OF MEDICINE. 

Snellen, and others, have published different series of test 
letters. Those of Jaeger begin with the smallest type used 
in printing, and gradually increase to letters of a size to be 
easily distinguished by a normal eye at a distance of twenty 
feet. Dr. Snellen's test types extend the scale, by means of 
letters made up of squares, to two hundred Paris feet. These 
two scales, which are the ones in general use, do not exactly 
correspond, that is to say, No. 20 Jaeger does not represent 
precisely the same point in the scale as Snellen, XX, and 
hence it is best to specify the particular scale employed in the 
test when the lower Nos. are used. 

Figures are placed above each series of letters, indicating 
the distance, in feet, at which they may be read by a normal 
eye. Thus, No. 10 should be read with ease at a distance of 
ten feet ; but if it can be read only at a distance of five feet, 
we say V, which expresses the acuteness of vision, 

_5_ 1 

10 2. 
If No. 18, which should be read by an emmetropic eye at 
eighteen feet, can be read only at a distance of twelve feet, 
we say 

V = — = - 
12 3. 

The numerical values found in thif manner do not always 

accurately represent the acuteness of vision, although sufficiently 

precise for all practical purposes. For example, a sharpness of 

6 4 3 

— — or - 

18, 12 9. 

js not necessarily the same as -J- ; for eyes that see No. 18 at 
six feet, may not see No. 9 distinctly at three feet, or No. 3 at 
one foot. Hence, as Stellwag points out, if we would represent 
accurately the state of vision, we must avoid all reduction of 
the fraction. 



DISEASES OF THE EYE. 373 



DIV. VL— FUNCTIONAL DISEASES. 

The diseases which we propose to consider in this section, 
are those functional disorders immediately influencing the 
accommodation, more especially asthenopia, and paralysis and 
spasm of the ciliary muscle ; those of refraction, namely 
myopia, hypermetropia and astigmatism ; those affecting the 
optic nerve and retina, particularly hyperaesthesia, anaesthesia, 
amblyopia, hemeralopia, and amaurosis ; and those involving 
the ocular muscles, especially nystagmus and strabismus. 
Assuming that the reader is already sufficiently acquainted 
with the refractive properties of the different kinds of lenses, 
we shall proceed at once to consider 

l.-THE THEORY OP ACCOMMODATION. 

It is assumed, in the first place, that all rays emanating 
from distant objects, by which is meant all objects at or 
beyond twenty feet from the observer, are parallel ; that is, 
the divergence being too slight to be taken into account, the 
objects are considered as if they were placed at an infinite 
distance. Such rays the refractive media of an emmetropic 
eye, when in a state of rest, are adapted to bring to a focus 
upon its retina, and thus to produce distinct images of the 
objects from which they emanate. The eye is then said to be 
accommodated for its far point, (punclnm remotissimuni), 
denoted by the letter r. Being thus adjusted for parallel 
rays, the normal eye perceives distant objects without any 
effort of the accommodation. And since the more distant 
the object the more nearly are the rays from it rendered 
parallel, it follows that the furthest point of distinct vision 
must be at an infinite distance. 

But if the rays, instead of being parallel, are very diver- 
gent, as in the case of very near objects, the state of refraction 
of the normal eye is such that they can only be brought to a 



374 PRACTICE OF MEDICINE. 

focus behind the retina, unless it can increase the amount of 
refraction sufficiently to focus them upon the retina. Now the 
normal eye is provided with an apparatus by which it is 
enabled, intuitively and unconsciously, to increase or diminish 
at pleasure the amount of its refraction, and thus to adjust 
itself for near vision. When thus adjusted, the eye is said to 
be accommodated for its near point, (punctum proxirnum), 
denoted by the letter/. 

The distance between these two points is called the range 
of accommodation, and is expressed by the letter A. In the 
youthful emmetropic eye, it extends from about three and a 
half or four inches, the nearest point of distinct vision, to the 
furthest point, which, as we have seen, lies at an infinite 
distance. Anywhere between these points objects may be 
distinctly seen ; but beyond the point for which the eye is 
accommodated, circles of dispersion are formed upon the 
retina, and the images appear blurred. 

If, as proposed by Prof. Donders, the range of accommo- 
dation be expressed by i, the distance of the near point (p) 
from the eye, measured from the nodal point, by h and that of 
the far point (r) by £, its value in any particular case may 

be readily determined by the formula 

i 1 i 

A P R. 

Thus, in an emmetropic eye, if the nearest point at which 

vision is distinct is 5", and the furthest point is an infinite 

distance, qq, we have by the above formula 

1 1 1 1 

A 5 00 5. 

Here the range of accommodation is represented by what 
is called a 5 inch lens ; that is, it would require a convex lens 
of five inches focus to be placed before the eye, to render the 
rays coming from an object placed at the near point (5") 
parallel, or what is the same thing, give them the direction 
they would have if the object were situated at an infinite 
distance. 

The theory of accommodation upon which these con- 



THE THEORY OF ACCOMMODATION. 375 

elusions are based, and which is now generally accepted as the 
true one, though ably advocated by Thomas Young as early 
as the beginning of the present century, did not receive a full 
and satisfactory demonstration until Cramer and Helmholtz, 
working independently of each other, furnished, by means of 
ingeniously devised instruments, incontestable proof of the 
alterations of curvature in the crystalline lens, when the eye is 
accommodated for near and distant objects, and at the same 
time proved that no change occurs in the curvature of the 
cornea. 

The changes in question may be readily demonstrated, 
ocularly, by placing a lighted candle at a certain distance to 
the right of a given fixed point, P, towards which the observed 
eye is steadily directed, while the eye of the observer is 
situated at an equal distance to the left of the same point. 
Fig. 18, representing the pupil of an eye 
thus observed in a state of rest, (r), 
shows the three images formed by reflec- 
tion from the cornea, (a), anterior capsule, 
(b), and posterior capsule, (c). Fig. 19 
shows the same eye in a state of accom- 
modation for the near point, (/); the 
pupil is somewhat contracted, as shown by the circular white 
line, and the image forms by the anterior capsule, (b), is found 
to be changed both in size and position. The image is 
^^^ rendered smaller in consequence of the 

increased curvature of the anterior 
surface of the lens, which forms a convex 
reflector of less radius. The change of 
position is due to the projection forward 
of the reflecting surface, in consequence 
of the lens being increased in thickness 
during accommodation. The other images have undergone 





37^ PRACTICE OF MEDICINE. 

no perceptible change, showing that neither the curvature of 
the cornea, nor the curvature or position of the posterior 
surface of the lens, undergo any perceptible change during 
accommodation. 

Fig. 20. 




In full accom. Eye at rest. 

Fig. 20 illustrates the changes which occur during accom- 
modation. The right half of the figure represents the eye in 
a state of rest, i, e., when accommodated for distance ; the left 
half shows it when fully accommodated for near vision. The 
relative difference in curvature of the anterior surface of the 
lens, on the two sides, corresponds very closely with the 
measurements of Cramer and Helmholtz. According to the 
latter, the changes that occur during accommodation for near 
objects are, (1) contraction of the pupil; (2) the pupillary 
margin of the iris is pushed forward ; (3) the peripheral 
portion of the iris moves backwards. (4) the anterior surface of 
the lens becomes more convex, and is arched forward, so as to 
render the lens considerably thicker in the antero -posterior 
diameter, and give it much greater refractive power ; (5) the 
posterior surface of the lens is also rendered more convex, but 
not to such a degree as to cause any perceptable change in its 
position. 

It was formerly supposed that whilst the chief influence 
concerned in the function of accommodation is exerted through 
the action of the ciliary muscle, the iris also materially assists 



THE THEORY OF ACCOMMODATION. 377 

in the process ; but as the accommodation has since been 
found to remain unimpaired, in a case in which the entire iris 
was removed after an accident, there can no longer be any 
room for doubt that the change in the form of the lens is 
wholly due to the action of the ciliary muscle. But the 
manner in which the muscle causes the change in question has 
not yet been satisfactorily answered. The most probable 
explanation is, that, so long as the ciliary mucles continues 
passive, the lens remains in its usual condition ; but as soon 
as the muscle contracts the suspensory ligament becomes 
relaxed, and the lens then increases its convexity by virtue of 
its own elasticity. 

Another factor in the procees of accommodation was, 
until recently, supposed to exist in the action of the internal 
recti muscles, in causing the necessary convergence of the 
optic axes for binocular vision ; but a case of Von Graefe's, 
in which all the external muscles of both eyes were completely 
paralyzed, and yet the power of accommodation remained 
unimpaired, clearly proves the contrary. 

It is thus seen that refraction and accommodation are 
two entirely different processes. The former is a passive 
condition, depending wholly upon the focusing power of the 
dioptric apparatus, which is chiefly due to the form of the eye 
and of its different refracting media. In these respects the 
eye does not essentially differ from any other optical instru- 
ment, the images being formed agreeably to the well-known 
laws of optics. Accommodation, on the other hand, is a 
purely physiological process, being the result of muscular or 
vital action, and is none the less real in consequence of being, 
for the most part, unconsciously and involuntarily performed. 

That the focusing power of the crystalline lens is 

controlled by the action of the ciliary muscle, is clearly 

proven by the suspension of the function whenever paralysis 

of the muscle occurs from disease, or whenever it is artificially 

induced by the action of Atropine. 
48 



378 PRACTICE OF MEDICINE. 

2.-AN0MALIES OF ACCOMMODATION. 

Having shown that the function of accommodation is 
dependent upon the action of the ciliary muscle, it remains to 
consider the principal causes which are known to limit or 
disturb the process. These are, (i), presbyopia, which is a 
limitation of the function due to advancing age ; (2), paralysis 
of the ciliary muscle, which is occasionally met with after 
severe illness ; and, (3), spasm of the ciliary muscle, which is 
frequently the result of over-working the muscle in accommo- 
dation. 

A.— Presbyopia. 

This affection, which was formally supposed to arise from 
deficient refractive power, is now known to have very little 
effect upon distant vision, the actual change consisting in the 
recession of the near point, and consequently in a limitation 
of the range of accommodation. This removal of the near 
point from the eye, is caused by senile changes in the crystalline 
lens, whereby its hardness is increased, so that its form becomes 
less and less susceptible of alteration from the action of the 
ciliary muscle, and hence the function of accommodation 
correspondently impaired. As this increase in the density of 
the crystalline is a purely physiological process, it may 
commence at any age, and may affect both emmetropic and 
ametropic eyes. In point of fact, it is found to begin very 
early, gradually increasing with advancing years, until, at the 
age of forty or forty-five, the near point is at eight inches from 
the eye, the distance which, for the sake of definiteness, has 
been selected as the limit from which to reckon the commence- 
ment of presbyopia. As age advances the refractive power 
of the lens also suffers, so that the eye not only becomes 
presbyopic, but hypermetropic. 



PRESBYOPIA. 379 

As presbyopia diminishes the range of accommodation, 
it cannot be of benefit, as is frequently supposed, to the 
myopic eye. It is true, the senile changes in the refractive 
power of the lens will have a slight tendency to diminish the 
myopia, and if moderate may serve to correct it ; but as the 
far point remains pretty much the same, the only effect will be 
to shorten the range of adaptation, which is already greatly 
reduced by the approximation of the far point. Presbyopia 
supervening upon hypermetropia is, of course, still more 
serious, loss of accommodation being added to diminished 
refraction. 

Since no effort of the ciliary muscle will render the lens 
sufficiently convex for near vision, it should be aided by suit- 
able glasses. The patient should be advised to commence 
their use as soon as the presbyopia begins to be noticed, and 
not postpone wearing them under the mistaken notion that he 
may thereby be enabled to dispense with them altogether, for 
this will necessarily fatigue and strain the accommodative 
apparatus, and may possibly result in even more serious 
disability. 

The strength of the required glasses may be easily found 
from the formula 

Pr = i-± 

8 P' 

where Pr donotes the degree of presbyopia, 8" the presbyopic 
near point, and p' the observed power of the presbyopic eye. 
For example, if we find the nearest point of distinct vision to 
be twenty-four inches, then the value of Pr will be 

8 24 12 > 

that is, it will take a convex lens of twelve inches focal length 
to neutralize the presbyopia, and enable the patient to see 
clearly at the distance of eight inches. 

If the presbyopia is complicated with myopia or hyper-^ 
metropia, it may become necessary to supply the patient with 
two sets of glasses, the myope with convex glasses for small 



380 PRACTICE OF MEDICINE. 

objects, to remedy the loss of accommodation, and concave 

glasses for distance, to neutralize the increased refraction ; 

while the hypermetrope will require two pair of convex glasses, 

one for near vision, to compensate for deficient refractive power 

and the loss of accommodation, and the other far distant 

vision, to neutralize the hypermetropia. 

To ascertain the range of accommodation for presbyopic 

eyes, we may make use of the formula already given, namely, 

i i i 

A P R. 

Thus, if the near point (p) be at fifteen inches, and the 

far point (r) at infinite distance (oo ), we have 
i _i i j_ 

A 15 oo 15. 

In choosing glasses it is well not to be governed too 
rigidly by Donder's near point (8"); but to be influenced to 
some extent by the distance at which the patient has been 
accustomed to read or sew. If this has been at a considerable 
distance, it will be more convenient not to have the near point 
brought within ten or twelve inches. We should also be 
guided in this matter by the range of accommodation. If this 
is large, we may, if the patient prefers, bring the near point to 
eight inches, or even less if the sharpness of vision is dimin- 
ished ; but if the range of accommodation is greatly lessened, 
weaker glasses should be selected, as these will be less fatiguing 
to the eye ; such, for example, as will enable the patient to 
read No. I of the test types at about twelve inches. 

B.— Paralysis of the Ciliary Muscle. 

This affection, which is not of very frequent occurrence, 
sometimes follows exhausting diseases, especially diphtheria. 
Paresis, or partial paralysis, is occasionally associated with 
general atony of the muscular system, and is then apt to be 
mistaken for amblyopia depending upon general debility. 

As the paralysis lessens or destroys the power of accom- 



SPASM OF THE CILIARY MUSCLE. 38 1 

modation, emmetropic eyes are unable to accurately distinguish 
near objects, though their ability to see distinctly at a distance 
is not impaired. But its effect upon vision is most marked 
in hypermetropic eyes, as these are obliged to exercise the 
function of accommodation even at a distance, and consequently 
lose the power of seeing any object with distinctness, whether 
near or remote. The myope, on the contrary, only becomes 
aware of the defect when looking at very near objects. If 
the paralysis is incomplete, these effects will, of course, be less 
considerable. In the latter case the symptoms may be 
mistaken for those of asthenopia, unless the range of accom- 
modation is also examined. This is all the more necessary 
in these cases, because, in simple paresis, the contractility of 
the pupil and the various movements of the globe generally 
remain unimpaired ; whereas in complete paralysis of the 
accommodation there is almost always dilatation of the pupil 
and divergent strabismus. 

TREATMENT. — This consists chiefly in perfect rest of the 
eyes, and the employment of such hygienic measures as are 
best calculated to invigorate the general system. If the 
patient is obliged to exercise his accommodation, he should be 
supplied with such convex glasses as will enable him to see 
distinctly without exertion, being careful to gradually diminish 
the strength of the lenses, in proportion as the accommodative 
faculty improves. 

The remedies which have hitherto proven most beneficial 
in this affection are : Caust., Physostig. ven. (used externally), 
and electricity ; good results have also been obtained in some 
cases from the internal administration of Arg. nit., Arn., Cup. 
acet., Euph., Gels., Kali iod., Opium, Paris q., and Rhus tox. 

C— Spasm of the Ciliary Muscle. 

This is not, as was formerly supposed, a very rare affection, 
being sometimes associated with both myopia and hypermetro- 
pia. It is most frequently met with in young subjects who 



382 PRACTICE OF MEDICINE. 

have strained their eyes in reading or fine work, the spasm 
being the result of over-tasking the ciliary muscle, in accom- 
modating the eye for near objects. This causes an apparent 
myopia, so that the patient sees better through concave glasses ; 
but if we paralyze the ciliary muscle by means of Atropine, we 
shall generally find that the eye is really hypermetropic. 
Such persons perceive distant objects very indistinctly ; and 
although near objects may be seen clearly for a short time, 
the effort at accommodation soon fatigues the eye. The pupil 
is generally contracted ; and the iris is bulged forward by the 
increased curvature of the lens. If we examine with the 
ophthalmoscope, we shall find that the refraction is highly 
hypermetropic, and that the optic disc and retina are more or 
less hyperaemic ; there is also, not unfrequently, a co-existing 
posterior staphyloma. 

Treatment. — The most speedy and effective treatment 
consists in completely paralyzing the ciliary muscle with 
Atropine. For this purpose we require a strong solution, say 
four or five grains to the ounce, which should be used three or 
four times daily, until the spasm is entirely overcome. If it 
returns we should enjoin complete rest of the eye, and endeavor 
to improve the general health by regular out-door exercise, 
and other hygienic means. If necessary, we should prescribe 
strong convex glasses for near objects, and weak ones for 
distance, the regular use of which will diminish the spasm by 
producing complete rest of the accommodation. Internally, 
we obtain the best result from the Physostigma ven. 

3 -ANOMALIES OF REFEACTION. 

An emmetropic eye is one whose dioptric media possess a 
refractive power just sufficient, when the accommodation is at 
rest, to form well-defined images of distant objects upon the 
retina ; it also possesses the power of increasing or diminishing 



MYOPIA, 383 

the refraction at pleasure, thus adapting itself to distinct 
vision at any distance. But there are eyes which do not 
possess these optically normal powers, namely, those in which 
the optic axis is too long, constituting myopia; those in which 
it is too short, producing hypermetropic/, ; and those in which 
the cornea or lens have an unequal curvature in different 
meridians, giving rise to astigmatism. 

A.— Myopia, 

NEAR -SIGHTEDNESS. 

We have already remarked, that in the myopic eye 
parallel rays are brought to a focus before reaching the retina. 
This optical defect is due to the refractive power of the eye 
being relatively in excess ; that is, although the refractive 
power may not be too high for a normally constructed eye, it 
is so in relation to the myopic eye, the antero-posterior axis of 
which is too long. It was formerly supposed that in myopia the 
cornea or lens was too convex, or that the latter was misplaced ; 
but exact measurements have shown this not to be the case, 
and that the lengthening of the optic axis is due to a bulging 
of the posterior portion of the globe, in consequence of which 
the retina is situated too far back of the lens and cornea. 
The consequence of this displacement is, that while divergent 
rays, or those coming from near objects, may be brought to a 
focus upon the retina, and thus afford distinct vision when the 
accommodation is at rest, parallel rays, or those coming from 
distant objects, form upon that membrane greater or less 
circles of dispersion, which render the images indistinct. It 
does not necessarily follow, however, that because a patient 
holds small objects very near to his eyes, or because he cannot 
see well at a distance, he is myopic, as similar symptoms may 
occur in hypermetropia. But if, in proportion as the object is 
removed from the eye, the vision becomes rapidly indistinct, 



384 PRACTICE OF MEDICINE. 

and there is no other apparent cause, we may strongly suspect 
the existence of myopia ; and if the vision is greatly improved 
by the use of weak concave lenses — say of thirty or forty 
inches focus — the myopic condition is rendered almost certain. 
But, as slight changes in refraction may be overcome by the 
accommodative power, and also by extreme degrees of myo- 
pia, it is better to ascertain at once the far point, and then, by 
placing concave glasses of the corresponding number before 
the patient's eyes, he will, if myopic, be able to see clearly at 
a distance, and there will no longer be any doubt. 

We may also determine the existence of myopia with the 
ophthalmoscope. If we make use of the direct method of ex- 
amination, we may be able to perceive the details of the fundus 
at some distance from the eye, and if we move our head to 
either side, we shall find that the retinal image moves exactly 
in the contrary direction. But in order to obtain a distinct 
image of the fundus, we shall, if the eye is strongly myopic, 
require a concave correcting lens behind the mirror. We shall 
now probably discover that the malformed eye is also a dis- 
eased one, there being, in the majority of cases, a greater or 
less degree of posterior staphyloma. This condition, which 
exists chiefly in progressive myopia, is generally associated 
with a sclero-choroiditis posterior. If the myopia is stationary, 
or but slowly progressive, it causes but little inconvenience in 
reading, sewing, etc ; but if rapidly progressive, it is apt, in 
consequence of the choroiditis, to be accompanied with symp- 
toms of high irritation and inflammation, and may even prove 
a source of great danger to the eye. (See Sclero-choroiditis 
Posterior) 

Myopia is frequently congenital, and sometimes heredita- 
ry, but the researches of Dr. Cohn and others show that, in all 
probability, it is very often acquired. Dr. Cohn found that, of 
one hundred and thirty-two compositors, more than half (51,5 
per cent.) were myopic ; and of the sixty-eight myopes, not 



MYOPIA. 385 

less than fifty-one (y$ per cent.) were possessed of normal 
vision in early life. It is almost certain that the continuous 
use of the eyes for near objects, especially by the young, is a 
fruitful cause, if not of the origin of myopia, at least of its de- 
velopment. Out of ten thousand and sixty school children 
examined, this investigator found one thousand and four my- 
opes, the proportion increasing in the higher departments, ac- 
cording to the increased demand for study. Thus, of the four 
hundred and ten students in the University of Breslau nearly 
two-thirds were affected with a greater or less degree of myo- 
pia. 

Treatment. — This will vary according as the myopia is 
stationary or progressive. The latter, if marked, and especially 
if occurring in youthful subjects, will require similar treatment 
to that recommended for Sclero-choroiditis Posterior (which 
see). But if stationary, or if the progress is too slow to be 
perceptible, and especially if it does not give rise to any mark- 
ed inflammatory symptoms, no preliminary medical treatment 
will be called for, and we may immediately proceed to select 
the requisite glasses. 

It is very important that the strength of the glasses re- 
quired for correcting the refraction should be determined with 
the greatest accuracy. As the degree of myopia (M.) is meas- 
ured by the far point (r.) for distinct vision, we first determine, 
by means of the test types, the furthest point at which the 
patient can clearly distinguish the letters. For example, if 
he reads No. 1 with facility at one foot, but is unable to distin- 
guish No. 2 clearly at two feet, or No. 3 at three feet, and so 
on, and yet is able to read No. 2 easily, say at twenty inches, 
we represent the degree of myopia by the formula, 

M = — > 

20 

twenty inches being the furthest point at which vision is dis- 
tinct ; it will, therefore, require a concave lens of twenty inches 

focus to neutralize the myopia. But, although No. 20 is theo- 
49 



386 PRACTICE OF MEDICINE. 

retically the proper glass, it is rarely the case that the strength 
can be accurately determined in this manner; as a general 
rule the glass will be found somewhat too strong, and will re- 
quire to be corrected by subtracting the power of the weak 
convex lens necessary to correct it. On the other hand, if the 
original glass is too weak, we should add the power of the weak 
concave lens required to give it the appropriate strength. The 
correction is made according to the following formula : 

a±b 

x= , 

ab 

that is, the power of the required lens (x) is equal to the sum 
or difference of the powers of the two lenses divided by their 
product. Take, for example, the case above cited. We first 
try the patient with a pair of 20-inch concave glasses, and di- 
rect him to read, say No. XX. Snellen at twenty feet. He will 
no doubt notice at once a marked improvement in his vision. 
We now place in front of the former glasses a very weak pair, 
say No. 60 concave, and, if his vision is still further improved, 
the original pair are too weak. Suppose that upon repeated 
trial this No. 60 concave is found to be the best corrective of 
the first pair of glasses, then, according to the formula 

a±zb 20-J-60 
x= = 



— — T5"J 

ab 20X60 



which gives concave 15 as the proper glass. But suppose, in- 
stead of a No. 60 concave, it takes a No. 60 convex to render 
distant vision distinct through the original glasses. This proves 
that the latter are too strong, and we have 

a±b 60 — 20 

x= === — tct > 

ab 60X20 

Showing that only a concave 30 would be required to correct 
the myopia.* 



*Convex lenses are generally designated by the positive or + sign, and concave lenses 
by the negative or — sign. If two or more are used in conjunction, the power of the com- 
pound lens will be represented by their sum, if the signs are alike, and by their difference, 
if unlike. 



MYOPIA. 387 

If the patient wishes to procure glasses for some special 
purpose, such as reading music, he will need a pair of less 
power than those required for distant vision. For example, if 
his myopia =J-, and he wishes to read at twenty-four inches, 
the formula will be 

~~ 6 "•" TZ J; 

Hence a concave 8 will be required. 

In order to decide the question as to whether or not it will 
be proper to allow the use of glasses for near objects, it will be 
necessary to determine the range of accommodation. For this 
purpose, we may make use of the method already given ; that 
is, we first find the nearest and furthest point at which No. I 
of the test types can be clearly distinguished, and then deduct 
one from the other, according to the formula 



For example, suppose the far point is at eight and the near 
point at two inches ; then we have 

A 2 8 2-| 

But this method is less certain than that of Prof. Donders, 
which only requires the patient to accommodate for his far 
point. Having first neutralized the myopia, which is done by 
using such concave glasses as render distant objects distinct 
(No. 20 at twenty feet), the near point is ascertained by requir- 
ing the patient to read No. 1 of the test types. Suppose this 
point is found to be at three inches ; then, as r=oo , and p=3 /r , 

we have 

1 1 1 1 

a 3 <» 3. 

If only one pair of glasses is used, it is safest to wear 

those which do not quite neutralize the myopia. If of full 

strength they will be too strong for near vision, and will be 

likely to overtask the accommodation. To prevent this, the 

confirmed myope generally employs only one eye for near ob- 



388 PRACTICE OF MEDICINE. 

jects, and thus avoids the convergence of the optic axes re- 
quired in binocular vision. But this leads insensibly to a still 
greater evil, namely, divergent strabismus, which is found to be 
of very frequent occurrence in myopia. We should be careful, 
therefore, to follow the advice of Prof. Donders, and prescribe 
only "spectacles so weak as to avoid these results." 

B. — Hypermetropia. 

This affection, the opposite of myopia, was formerly con- 
founded with presbyopia ; or, rather, the condition now called 
hypermetropia was regarded as a particular form of presbyo- 
pia. This opinion, however, was erroneous, the refractive 
power for distant objects being normal in presbyopia, whereas 
in hypermetropia it is deficient, in consequence of the shorten- 
ing of the optic axis ; hence parallel rays are brought to a focus 
behind the retina, and only convergent rays come to a focus 
upon it. And since in this affection even parallel rays require 
an effort of accommodation to concentrate them upon the re- 
tina, it follows that, although hypermetropic eyes may be able 
to accommodate themselves to distinct vision for a short period, 
the constant use of them must soon become fatiguing and pain- 
ful, especially for near objects. In fact, this is often the most 
obvious symptom in hypermetropic eyes ; for while there may 
be no apparent disease existing, the vision being pt^fectly good, 
the eyes are incapable of continued use, especially upon small 
objects, without causing so much fatigue and confusion of sight 
as to compel the patient to desist from his employment, (as- 
thenopia). 

Prof. Donders divides hypermetropia into three forms, 
namely, the faculative y the relative, and the absolute. The fac- 
ulative form is that in which the eye readily accommodates 
itself for all distances, and the patient experiences no fatigue 
while at work ; but presbyopia sets in early, accompanied by 



HYPERMETROPIA. 389 

symptoms of asthenopia. In the relative form of hyperme- 
tropia, the eye is also enabled to accommodate itself for any 
distance, but only by great effort, and by a too strong con- 
vergence of the optic axes. This form, which generally oc- 
curs soon after puberty, is always attended with more or less 
asthenopia. Absolute hypermetropia, on the contrary, is a 
form in which no effort of the accommodation will enable the 
patient to see distinctly, without glasses, at any distance. It 
generally occurs at a later period in life than either of the pre- 
ceding forms. 

If we examine the hypermetropic eye with the ophthal- 
moscope, by the direct method, we get an erect image, con- 
trary to what occurs in the myopic eye ; for if we fix our at- 
tention upon any of the details of the fundus, such as the optic 
disc or retinal vessels, and move our head to either side, the 
image is seen to move in the same direction. By the indirect 
method, the image appears much larger than it does in the em- 
metropic eye, in consequence of its being formed further from 
the object lens. 

As the asthenopic symptoms depending upon hyperme- 
tropia may be cured by the use of spectacles, it is important, 
in order to select the proper glasses, to ascertain the actual de- 
gree of hypermetropia. This is often considerably greater 
than the manifest hypermetropia, (Hm,) in consequence of a 
certain amount being rendered latent by the accommodative 
power, (HI,) which, as we have seen, is exercised to some ex- 
tent at all distances. Hence it becomes necessary to paralyze 
the ciliary muscle by Atropine, before we can estimate correct- 
ly the amount of absolute hypermetropia, (Ha). If we then 
test the vision for distance, we shall find that the patient re- 
quires the aid of a convex lens, or if presbyopic, he will require 
much stronger glasses than he did before the accommodative 
function was suspended. The power of these glasses being 
the measure of the absolute hypermetropia, the latter may be 
expressed by the formula, Ha = --- etc. 

r J 10. 16. 20, 



390 PRACTICE OF MEDICINE. 

Having neutralized the hypermetropia by the proper 
glasses, we may readily ascertain the range of accommodation 
hy measuring the nearest point at which the patient can dis- 
tinctly read No. I of the test types with these glasses. In 
young individuals, in whom the accommodative power is gen- 
erally very strong, it often amounts to - or even - 

Hypermetropia is of frequent occurrence in childhood, 
and is often hereditary. It is generally caused, however, by 
senile degeneration of the lens, the latter becoming more and 
more flattened and less susceptible of a change of form by the 
accommodative power. It may also be caused artificially, by 
removing the lens from the optic axis, as in operations for cat- 
aract. In these cases, the power of accommodation is entire- 
ly lost, and the hypermetropia is always absolute. 

According to Dr. Cohn, nearly two-thirds of the cases oc- 
curring in childhood lead to convergent squint. Later in life 
it causes accommodative asthenopia. As age increases, the 
range of accommodation diminishes, and the patient can only 
see large and remote objects. 

TREATMENT. — We have already pointed out the principles 
to be observed in the selection of the proper convex glasses, 
the use of which constitutes the only scientific treatment of 
this affection. They should be prescribed upon the first ap- 
pearance of asthenopic symptoms. It is important that they 
should not be too strong. De Wecker recommends the neu- 
tralization of the manifest, and about one-fourth of the latent 
hypermetropia, for near vision ; but even these glasses are 
sometimes found to be too strong for the patient. The only 
safe rule is, to prescribe glasses which may be used for a length 
of time without causing any sense of fitigue or pain to the eye. 
They will generally be found to be glasses of about thirty 
inches focus. 

In order to cure the asthenopia, it will often become nec- 
essary, after a few weeks, to change the first pair of glasses for 



ASTIGMATISM. 39 r 

stronger ones. If the hypermetropia is faculative, the cure is 
generally soon accomplished, and the glasses may then be dis- 
pensed with ; but if the hypermetropia is relative or absolute, 
their use, even for distant vision, will require to be continued. 
The main point in treatment is, to relieve, and at the same 
time strengthen, the power of accommodation. Hence the 
patient should never attempt to read or work without the aid 
of glasses, and should always rest the eyes whenever they be- 
come weary. He will find it beneficial, also, to follow the 
advice of Dr. Dyer, and exercise the eyes for a few minutes 
every day, at stated hours, in reading with proper glasses, grad- 
ually increasing the time as the eyes improve, observing at the 
same time not to overtask the accommodative power. 



C— Astigmatism. 

We have hitherto regarded the dioptric apparatus as being 
perfectly symmetrical, and its different planes as having one 
and the same focus. But this is not the case even with the 
normally constructed eye, as it is found that rays entering it 
in the vertical meridian are generally brought to a focus sooner 
than those which enter it in the horizontal direction. This 
variation in the refraction of the eye in different planes, which 
exists in nearly all eyes, is too slight to exercise any percepti- 
ble effect upon vision. But abnormal astigmatism, which 
generally results from a marked want of symmetry in the curv- 
ature of the cornea, makes the refractive power of the eye so 
unequal, in one or another of its meridians, as to confuse the 
retinal image and render it more or less indistinct. Similar 
effects may also be produced by a similar irregularity in the 
curvature of the lens, but such cases are comparatively rare. 
Nor is it every case of irregular corneal refraction that is in- 
cluded in our inquiry ; for such symptoms as occasionally re- 



392 PRACTICE OF MEDICINE. 

• 
suit from the cicatrization of corneal ulcers have already been 

considered. (See Keratitis, etc.) 

Regular astigmatism may be either simple, compound or 
mixed. It is called simple when one meridian of the cornea is 
normal, or emmetropic, and the other myopic or hypermetropic. 
It is compound when both meridians are myopic or hyperme- 
tropic, but in different degrees. It is termed mixed astigma- 
tism when one meridian is myopic and the other hyperme- 
tropic. 

One of the most convenient tests of astigmatism is, to have 
the patient look at the cross-bars of a window, and if he sees 
either the perpendicular or the horizontal bars more clearly 
than the others, he is astigmatic. Or he may be examined 
in a similar manner at different distances with Snellen's large 
test types, say No. LXX or C, and if a point can be found at 
which one portion of the letters appear clear and the other por- 
tions indistinct, the defect in vision is due to astigmatism ; 
otherwise it must be referred to some other cause. 

The readiest method of determining the exact direction of 
astigmatism, is, to require the patient to look through a steno- 
paic disc, which consists of a metal plate perforated with a 
narrow slit. When this slit is held in a proper direction, that 
is, in a line with the emmetropic meridian of the cornea, the 
confusion of vision disappears, and the patient can see clearly. 
The degree of astigmatism may be ascertained by simply plac- 
ing convex or concave glasses before the slit until we find the 
number which renders vision most distinct. 

Treatment. — Stenopaic spectacles will suffice to correct 
simple astigmatism ; but the compound and mixed forms will 
require convex or concave cylindrical glasses, according as the 
astigmatism is hypermetropic or myopic. Cylindrical glasses 
cause no refraction in the plane of their axes, whilst those rays 
which pass through them at right angles to their axes are re- 
fracted most. Hence this line of the lens should be so placed 



} AMBLYOPIA. 393 

as to correspond with the line of the greatest astigmatism. 
Sphero-cylindrical glasses are required for compound astigma- 
tism, one surface being convex- or concave-spherical, to correct 
the hypermetropia or myopia, and the opposite surface cylin- 
drical to correct the astigmatism. Mixed astigmatism requires 
bi-cylindrical glasses for its rectification, one side of which is 
concave, to suit the myopic meridian of the eye, and the other 
convex, to suit the hypermetropic meridian. 

The selection is best made by trial. We first ascertain 
how much vision can be improved by means of the ordinary 
convex or concave glasses. We then select a convex- or con- 
cave-cylindrical glass of corresponding strength, and rotate it 
before the eye until its axis is brought into the right direction 
to correct the astigmatism. If it is found too weak or too 
strong we try others. 

Having ascertained by trial the exact angles which the 
transverse diameter of the glasses makes with that of the eye, 
the greatest care should be taken to have them set in precisely 
the same position in the frames, as the least deviation from 
the proper plane will lessen or destroy their beneficial effect. 
For the same reason, spectacles are to be preferred to eye- 
glasses, the latter being less nicely and less securely adjusted 
to the eye. 



^.-AMBLYOPIA. 

Amblyopia is a general name, used to denote any form of 
blindness not due to optical defect. Hence it embraces hy- 
peresthesia and anaesthesia of the retina, hemeralopia, or night- 
blindness, and even amaurosis ; though the latter term is some- 
times confined to cases of complete or absolute blindness, while 
the various degrees of impaired vision, except such as arise 

from anomalous refraction, are included under the term ambly- 
50 



394 PRACTICE OF MEDICINE. 

opia. In addition to the amblyopic affections above mention- 
ed, which will be separately considered, we note two distinct 
forms, namely, such as are due to functional disturbances of 
the circulation, and those which seem to depend upon a de- 
praved state of the blood, such as occurs in scarlet or typhus 
fever. Thus we have what is called ancemic amblyopia, from a 
deficiency of blood. This may originate in any of the causes 
which give rise to general anaemia, such as excessive haemor- 
rhage, hyper-lactation, etc. Congestive amblyopia, on the other 
hand, generally results from a suppression of some customary 
discharge, and is due to over-fullness of the vessels of the eye 
or brain. It is most apt to occur during gestation, amenorr- 
hcea, etc. Toxcemic amblyopia is commonly due to the pois- 
onous influence of such agents as tobacco, {amblyopia nicotiana), 
alcohol, {amblyopia potatorum), quinine, lead, etc. Urcemic 
amblyopia has ^already been referred to under the head of ne- 
phrite ietinitis, (which see). Transitory amblyopia sometimes 
occup»4n;tj^course of low diseases, such as diphtheria, scarla- 
tina, typhus fever, etc.; and it may also occur in connection 
with derangement of the stomach from indigestion, disease of 
the liver, etc. Finally, we have traumatic amblyopia, resulting 
from concussion, shock, lightning-stroke, etc. 

The ophthalmoscope reveals at first no abnormal appear- 
ance, unless a slightly hypersemic condition of the retina and 
optic nerve is regarded as such ; but even this is frequently 
wanting. Besides, the appearance in question is no greater 
than is frequently met with in a normal state of vision, and 
may therefore be regarded as physiological rather than patho^ 
logical. Subsequently, symptoms of atrophy of the optic 
nerve make their appearance, and then the disease assumes the 
character of amaurosis, (which see). 

PROGNOSIS. — This will depend chiefly on the nature of the 
cause, the length of time the disease has existed, and the age, 
habits, and constitutional condition of the patient. In most 



AMBLYOPIA. 395 

cases progressive atrophy of the optic nerve sooner or later su- 
pervenes, and then the vision, although it may not be entirely 
lost, is seldom capable of being fully restored. Von Graefe 
founds the prognosis upon the state of the pupil, especially in 
the transitory form of the affection ; for if the pupil reacts un- 
der the stimulus of light, he- regards the prognosis as favorable, 
even though all perception of light may have been lost. Cases 
have occurred, however, in which the pupils have retained their 
activity, and yet the sight has never returned. This is espe- 
cially the case with the blindness of pregnancy, many instances 
of which have terminated unfavorably. 

Treatment. — The treatment of amblyopia should be 
chiefly directed to the removal of the cause. Thus, anaemic 
amblyopia requires a liberal and nutritious diet, exercise in the 
open air, and such internal remedies as Anac, Ars., Chin., Ferr., 
Igna., Nux v., Phos. ac, etc. Congestive amblyopia, on the 
other hand, is most frequently benefited by such remedies as 
are specially suited to the characteristic symptoms, as, for ex- 
ample, Aeon., Puis., and Sep., in menstrual suppression ; Bry. 
and Cimicif., in rheumatic cases ; Cactus and Lycop. in heart 
troubles ; Bell, Cact., Gels., Glon., Phos., and Zinc, in hyperae- 
mia of the optic nerve ; Nux v., Sec. c. and Zinc, in paralysis 
of the retina ; Bell., Glon., Phos. and Sang., in cerebral conges- 
tion, etc. Amblyopia potatorum et nicotiana require the im- 
mediate and complete abandonment of the use of spirituous 
liquors and tobacco, and the internal administration of such 
remedies as are best calculated to invigorate the general sys- 
tem, especially Ars., Chin., Igna., and Nux v. Amblyopia 
saturnina has been greatly benefited by Opium. Traumatic 
cases, and such as result from fright or shock, are best treated 
with Ars., Coff., Cyp., Hyos., Igna., Scut., etc. 



39^ PRACTICE OF* MEDICINE. 

5 -HYPEEJESTHESIA RETINJE. 

SYMPTOMS. — This affection, which is frequently mistaken 
for inflammation of the retina, is characterized by symptoms 
of extreme irritation, such as severe photophobia, lachryma- 
tion and ciliary neuralgia, accompanied in some cases with 
spasmodic twitchings of the lids. The irritability of the retina 
is so intense as to give rise to painful photopsies, even in the 
dark. These generally take the form of spontaneous flashes 
of light, accompanied with sensations of dazzling before the 
eyes ; and are greatly aggravated by the least exposure of the 
eyes to light, or by motion, excitement, exertion, or pressure 
upon the globe. The sensibility of the retina is so much ex- 
alted, that former impressions are manifested for an abnormally 
long period ; and even the power of seeing in the dark (nycta- 
lopia), or with an insufficient amount of illumination for normal 
vision, has in some rare instances been observed. The so- 
called phosphenes, or luminous rings, such as appear when the 
globe is firmly pressed, likewise occur, either with or without 
the dazzling sensations and photophobia. Moreover, the for- 
mer, like the latter, may appear even in complete darkness. 
In some cases objects are seen as through a mist, or surround- 
ed by circles of various colors (ckromopsia). 

Examined with the ophthalmoscope, the eye is found to 
be free from every appearance of disease. The sight is good 
in a subdued light, but owing to an anaesthetic state of the pe- 
ripheral portion of the retina, the field of vision is considerably 
contracted. 

Etiology. — Hyperesthesia of the retina is most frequent- 
ly met with in patients of an excitable, nervous temperament, 
especially young and delicate females. It sometimes arises 
from irritation or congestion caused by exposure to very bright 
lights ; but the most common cause is straining or over-work- 
ing the eyes by strong artificial light. It may also result from 



ANESTHESIA RETINiE. 397 

-a blow or other accident about the eye ; but in many cases it 
can be traced to no apparent cause, unless it be an impaired 
state of the general health, such as comes from a disturbance 
of the menstrual function, etc. 

Treatment. — Blue glasses, which diminish equally all the 
rays of the spectrum, should be worn as long as the eyes are 
sensitive and painful, especially in the open air, and when ex- 
posed to bright lights. If the photophobia is very severe, it 
may be necessary for a time to exclude all rays of light from 
the eyes ; but as the irritation subsides we should gradually ac- 
custom them to bear the light, which in a mild form is not in- 
jurious to the retina. 

Internally we should prescribe such remedies as will ben- 
efit the general health, and at the same time ameliorate the 
local symptoms. We have generally obtained the best results 
from Bell., Cimicif., Con., Gels., Merc, Nux v. and Puis,; but 
have also derived benefit, in suitable cases, from Chin., Hep;, 
Igna., Nat. m., Sulph., and Tart. em. 



6.-ANJESTHESIA BETING. 

This condition, which consists in a diminished excitability 
of the retina, is unattended by any objective symptoms. It 
is chiefly characterized by the very feeble impression which 
moderate degrees of illumination make upon the eye ; and 
seems to arise from the blinding effect of intense light upon the 
nerve elements of the retina, whereby the latter appears to lose, 
to some extent, its power of responding to the stimulating effects 
of ordinary degrees of light. One of the most common forms 
of the affection, snow-blindness, is characterized by a dimness 
of vision which lasts as long as the affected eyes remain expos- 
ed to the dazzling reflection of the bright sunlight upon the 
snow or ice. 



398 PRACTICE OF MEDICINE. 

Partial anaesthesia generally results from direct or reflect- 
ed sunlight, or other strong light, acting suddenly or continu- 
ously upon the retina ; and usually takes the form of a dark 
cloud in the centre of the field of vision. This cloud is often 
temporary, lasting but a few hours ; but it may continue for 
several weeks or months, and then, if circumstances favor, grad- 
ually clear up and disappear. When confined to the periphe- 
ry of the retina, the visual field is more or less contracted, 
while the degree of central vision is generally but little, if at 
all, diminished. 

There is a monocular form of anaesthesia, usually called 
amblyopia exanopsia, which results from disuse of the eye, as in 
strabismus convergens, (which see). It is also frequently as- 
sociated with paralysis of the accommodative function. It is 
generally confined to the central portion of the visual field, and 
this will commonly serve to distinguish it from other pathogen- 
etic forms of anaesthesia, in which the periphery is mostly in- 
volved. 

Treatment. — This should consist in attention to the gen- 
eral health, regular exercise in the open air, rest and protection 
of the eyes, and the internal administration of Igna., Nux v., 
Sec. c, and Zinc. 

7-HEMERALOPIA. 

NIGHT-BLINDNESS. 

Symptoms. — Hemeralopia is characterized by a state of 
vision in which the patient sees well during the early part of 
the day, or when objects are brightly illuminated, but imper- 
fectly towards night. In high grades of the affection, the pa- 
tient is unable to distinguish even large objects towards the 
close of the day. This is not simply owing to the time of 
day, as was formerly supposed, but chiefly to the diminished 
intensity of the light ; for it is observed that, cceteris paribus. 



HEMERALOPIA. 399 

the degree of amblyopia corresponds with the amount of illu- 
mination, the patient being able to see even at night, provided 
the artificial light is sufficiently bright. It is true, however, 
that the patient can always see best in the morning ; but this 
may be accounted for, in part, by the reinforcement, so to 
speak, of the retinal sensibility during the night. It appears, 
therefore, that the dimness of vision is due to torpor of the re- 
tina ; an abnormally great amount of light being required in 
order to see distinctly. 

In the morning, or when there is sufficient illumination to 
see clearly, the pupil is generally of normal size and mobility ; 
but as night approaches, and the illumination decreases, it usu- 
ally becomes dilated and sluggish. In old and severe cases, 
however, the pupil is always enlarged and torpid, and it requires 
the stimulus of a very strong light to excite contraction. 

Hemeralopia is not always equally developed in both eyes, 
the patient being able sometimes to discern objects with one 
eye and not with the other ; or perhaps some parts of the 
visual field may be clouded over, while in the other eye it may 
be clear, and admit of a certain degree of indirect vision. 

ETIOLOGY. — The chief predisposing cause of this affection 
is an impoverished state of the blood, in consequence of which 
the nerve elements of the retina are insufficiently nourished. 
This accounts for the fact that soldiers and sailors suffering 
from scorbutic diseases, are especially prone to be affected with 
the disease. We also find that by far the largest number of 
hemeralopes are individuals whose constitutions have become 
impaired by severe illness, or whose general condition is one 
of debility. It is likewise owing to this cause, doubtless, that 
the disease sometimes prevails epidemically in camps, jails, 
poverty-stricken fever-districts, etc. 

The principal exciting cause of night-blindness is pro- 
longed exposure to intense and unaccustomed light. Hence 
its frequent occurrence in the spring and summer, increasing 



400 PRACTICE OF MEDICINE. 

in clear, and diminishing in cloudy weather. Hence, also, its 
frequent appearance amongst harvest hands, soldiers who 
exercise much in the sunlight, and sailors who are similarly- 
exposed within the tropics. 

Treatment. — The chief indications are, to restore the 
general health, and protect the eyes from bright light. If the 
case is very severe, or very chronic, the speediest way to effect 
a cure is, to apply a binocular bandage, or else confine the 
patient in a dark room, and feed him with the most nourishing 
and easily-digestible food, soups, etc. In this way, protracted 
cases have been cured in a very few days. 

Internally, the following remedies, which have given great 
relief in some cases, may be prescribed, the selection depending 
mainly upon the general condition of the patient : — Arg. nit., 
Chin., Hyos., Lyco., Ranun. bulb., Stram., and Sulph. 

8.-AMAUR0SIS. 

The term Amaurosis was formerly used to denote any 
impairment or loss of vision depending upon congestive, 
inflammatory, organic, or functional disease of the nervous 
apparatus of the eye, whether seated in the retina, optic nerve, 
or brain. At present its signification is more restricted, the 
term being mostly confined to cases depending upon degenera- 
tive atrophy of the optic nerve, while those arising from 
irregularities in the circulation of the nervous system, are 
included under the head of amblyopia, (which see). Amaurosis 
therefore differs from other amblyopic affections in being both 
functional and organic. 

SYMPTOMS. — The only characteristic symptoms of amauro- 
sis are ophthalmoscopic. Of these, the most marked are : 
a faint, white or bluish-white appearance of the papilla ; an 
absence, or diminution in the size of the nutritive 
vessels of the disc ; a contraction and attenuation 



AMAUROSIS. 401 

of the retinal vessels, especially the arteries ; and an 
opaque, somewhat irregular but sharply defined optic 
disc, which is often slightly excavated. The amaurotic 
excavation is liable to be mistaken for the physiological 
excavation, which is congenital and frequently seen in the 
normal eye, unless we bear in mind that in the latter the other 
symptoms of atrophy above-mentioned are absent, the optic 
nerve being in its normal state. In the amaurotic excavation, 
the retinal vessels are never displaced, as in glaucoma, the 
cavity being so shallow, and its edges sloped so gradually, that 
the vessels appear to pass over a nearly level surface. In 
many cases of spinal amaurosis, a bluish, or bluish-green 
discoloration of the papilla is especially marked, and is best 
seen by the direct method of examination. In other cases the 
disc appears pale and white, sometimes as white as paper. 
This is particularly the case in the form of cerebral amaurosis 
caused by the excessive use of tobacco. In the first stage of 
the tobacco amaurosis, which is one of congestion and very 
transitory, the disc is abnormally red ; this is followed by 
pallor of the outer half, or the part nearest the macula lutea ; 
finally, the whole disc becomes pale, white, and in an advanced 
state of atrophy. These changes all occur within a few 
months, during which the sight becomes progressively impaired, 
and often extinct. 

Etiology. - The most frequent cause of amaurosis is 
basilar meningitis, especially the chronic form. It may also 
be produced by chronic periostitis at the base of the brain, or 
by tumors within the brain or cerebellum. Other causes are : 
cerebral hemorrhages, epilepsy, and diseases of the spinal cord, 
especially chronic myelitis and locomotor ataxy. 

PROGNOSIS. — This will depend mainly upon the cause, 
the mode of attack, the state of the field of vision, and the 
condition of the optic nerve. All cases, of course, are serious, 
and should be considered more or less doubtful ; hence the 



402 PRACTICE OF MEDICINE. 

prognosis should always be guarded. Sudden attacks are gen- 
erally less unfavorable than the more gradual, especially in the 
case of children. Cases that remain stationary for a consider- 
able period are also hopeful, as they usually depend upon 
causes which are removable, or which are more or less amena- 
ble to treatment, such as the too free use of alcohol or tobacco, 
or some disorder of the stomach, liver, or uterine system, etc. 
So, also, if the visual field remains uncontracted for a consid- 
erable time after the disease sets in, or if the edges of the field 
are regular and well-defined, the prognosis is not altogether 
bad. On the other hand, irregular contractions, occurring rap- 
idly in both eyes,are very unfavorable ; and so, also, are central 
scotomata, especially if the peripheral portions of the field are 
likewise affected. Although the appearance of the optic nerve 
is not sufficient of itself to determine the result, yet atropic 
changes in it are always of serious import, and, in most cases, 
render the prognosis very unpromising. 

Treatment. — These cases will generally tax the skill of 
the practitioner to the utmost. To be successful even in a 
small proportion of cases, he will need to pay particular atten- 
tion to the cause, and to select his remedies with the greatest 
care. The hints and indications given under the head of Am- 
blyopia, are no less appropriate to the treatment of Amaurosis, 
and will be suggestive. In addition to electricity and the hy- 
podermic injection of Strychnia, both of which have been used 
with benefit, the following remedies, which have proven suc- 
cessful in some cases, should be carefully studied : -Aeon., 
Ars., Bell., Calc. c, Cimicif., Crotal., Gels., Glon., Hep., Igna., 
Lycop., Merc, Nat. m., Nux v., Phos., Puis., Ruta g., Sant, Sec. 
c, Sep., Sulph., Zinc. 



DISEASES OF THE EYE. 403 

9.-MYDRIASIS. 

ABNORMAL DILATATION OF THE PUPIL. 

SYMPTOMS.-^-This is a functional disease of the iris, char- 
acterized by an abnormal dilatation and immobility of the 
pupil. As slight degrees of dilatation seldom produce any 
special inconvenience, they are not apt to attract attention ; 
and hence the term is only applied to those cases in which the 
dilatation is well marked. The pupil is not always regular, 
the opening being sometimes greater in one direction than in 
another. Whatever may be its shape and size, the pupil is 
generally more or less fixed, varying but little, if at all 
under the stimulus of light, or from use. It is also less black 
than the normal pupil, in consequence of the increased illumi- 
nation of the fundus. The affection is generally confined to 
one eye. 

Vision is commonly more or less impaired, especially for 
near objects. This arises partly from glare or dazzling, in 
consequence of the dilated state of the pupil, and partly from 
the circles of dispersion formed upon the retina, in consequence 
of the loss of accommodation. The latter, however, is not 
always present, nor is there any fixed or necessary relation be- 
tween it and the degree of dilatation ; for this may be extreme 
and the ciliary muscle but little affected, and, on the other 
hand, if the mydriasis is but slight, the power of accommoda- 
tion may remain unimpaired. 

Etiology. — The causes of mydriasis, though numerous, 
may be reduced to a very few heads. When binocular, the 
disorder is due to some deep-seated intra-ocular disease affect- 
ing the sensibility of the retina, or to certain diseases of the 
brain, such as basilar meningitis, apoplectic effusions at the 
base of the brain, chronic hydrocephalus, and diseases of the 
cerebellum. In the great majority of cases, however, the my- 



404 PRACTICE OF MEDICINE. 

driasis is monocular, and is caused either by spasm of the dila- 
tor pupillae and of the vessels of the iris, arising from irritation 
of the oculo-pupillary branches of the sympathetic nerve — in 
which case the ciliary muscle, and consequently the power of 
accommodation, remains unaffected — or else it depends upon 
paralysis of the constrictor pupillae, in consequence of injury to 
the conducting power of the third nerve. In these cases there 
is often more or less paralysis of the accommodation, and in 
some instances the entire region supplied by this nerve is im- 
plicated, and then it is generally considered to be of rheumatic 
origin. In some cases, however, it is undoubtedly syphilitic. 
When due to irritation of the sympathetic ganglia, it can some- 
times be traced to helminthiasis, spinal irritation, derangement 
of the digestive organs, etc. To the same class, also, belongs 
the ephemeral mydriasis which has been observed only at cer- 
tain hours of the day, and which, as pointed out by Von Grsefe, 
is sometimes premonitory of insanity. 

Treatment. — This should be especially directed to the 
removal of the cause; foralthough Atropine, Bell, and other my- 
driatic remedies are homoeopathic to the condition of the iris, 
they cannot be expected to prove curative unless the cause it- 
self be removed. Hence, rheumatic cases call for such rem- 
edies as Bry., Cimicif., Colch;, Rhus., etc.; syphilitic cases for 
Merc, Kali iod.; traumatic cases, Arnica ; helminthiasis, Sant; 
paralysis, Nux v., Rhus., etc. When associated with paralysis, 
the treatment should generally be similar to that recommended 
for paralysis of the ocular muscles, (which see). 

10.— MIOSIS, 

ABNORMAL CONTRACTION OF THE PUPIL. 

Symptoms. — This affection, the opposite of mydriasis, is 
characterized by extreme contraction of the pupil, which is 
sometimes reduced to the size of a pin's head, and even less. 



PARALYSIS OF THE OCULAR MUSCLES. 405 

The pupil is regular in form, black, extremely limited and slug- 
gish in its movements, and yields but slightly to the influence 
of Atropine. 

Vision is generally impaired in proportion to the degree 
of contraction, the field of vision being greatly diminished and 
but feebly illuminated. In some cases the patient can see 
only during the middle hours of the day ; in other cases he 
may be almost totally blind. 

ETIOLOGY. — Myosis may be due to paralysis of the radi- 
ating fibres of the iris, or to spasm of the constrictor pupillae. 
The former is most frequently met with in disease or injury of 
the cervical portion of the spinal cord ; the latter in iritis and 
inflammations accompanied by great irritation of the ciliary 
nerves. It may also be caused by too great and long contin- 
ued use of the eyes in the examination of very small objects, 
as in watch-making, engraving, etc. 

Treatment. — As this disease is very rarely idiopathic, 
the treatment, to be effective, should be especially directed to- 
wards the removal of the cause. Simple idiopathic cases 
would probably be benefited by such remedies as Opium, Physo- 
stigma ven., etc. 

1L-PABALYSIS OP THE OCULAR MUSCLES. 

SYMPTOMS. — The symptoms vary according as the paraly- 
sis is complete or partial ; that is, according as it affects all or 
only a part of the muscles supplied by a particular nerve. 
Most frequently the affection is limited to the muscles furnish- 
ed by the third nerve, or motor oculi, namely, the rectus supe- 
rior, inferior, and internus. If the paralysis is complete, we 
have, in the first place, ptosis, or dropping of the upper lid, 
while the motion of the globe is restricted in the upward, down- 
ward, and inward directions ; but as the rectus externus still 
retains its power, the eye is readily turned towards the temple, 



406 PRACTICE OF MEDICINE. 

and may also be rolled somewhat downward and outward, 
through the action of the superior oblique. Subsequently, the 
sixth nerve generally becomes affected, and then the paralysis 
extends to the rectus externus. In this case the eye can no 
longer be turned towards the temple, but looks directly for- 
ward. Occasionally the fourth nerve becomes implicated, and 
gives rise to paralysis of the superior oblique. 

Diplopia, or double vision, is a very annoying symptom in 
these cases, and is sometimes the only one of which the patient 
complains. This symptom is always experienced when the 
patient endeavors to look in the direction opposite to that as- 
sumed by the affected eye. Thus, in paralysis of the superior 
rectus, the inferior oblique muscle will cause the eye to deviate 
outward, and crossed double images will appear in the upper 
half of the field of vision. On the other hand, if the paralysis 
affect the superior oblique, the deviation of the visual line will 
be but slight, the double images will be homonymous — that is, 
on the same side — and will be confined to the lower half of the 
visual field. 

Etiology. — Paralysis of the ocular muscles is most fre- 
quently found to be due to syphilis. Von Graefe refers nearly 
one-third of all cases to this cause. Many cases, however, are 
of rheumatic origin, or arise simply from exposure to damp and 
cold. Others, again, may be produced by some centrally act- 
ing cause, such as cerebral hyperaemia, effusion of blood, 
softening of the brain, hydrocephalus, etc. Occasionally, also, 
syphilitic nodes, tuberculous deposits, and tumors of various 
kinds, are so situated at the base of the brain, or within the 
orbit or cranium, as to press injuriously upon the affected 
nerves, and thus cause paralysis of the muscles to which they 
are respectively distributed. 

Treatment. — Recent cases, especially those of a rheu- 
matic or syphilitic nature, are found to be the most amenable 
to treatment. Bry., Caust, Cimicif., Euphr., and Rhus, are 



PARALYSIS OF THE OCULAR MUSCLES. 407 

generally indicated in the former, and Aurum, Kali iod., and 
Merc, in the latter. Of these, Causticum is the one most fre- 
quently and successfully employed, especially where the paral- 
ysis is caused by exposure to cold. The following remedies 
have also been recommended in particular cases : — Arnica for 
paralysis resulting from a blow or other injury ; Cup. acet. for 
paralysis of the nervus abducentis ; Senega for paresis of the 
superior rectus or superior oblique, especially when the diplo- 
pia is relieved by bending the head backwards ; and Spigelia 
when accompanied with sharp, stabbing pains. Alum., Con., 
Gels., Hyos., Igna., Nux v., Phos., and a few other remedies, 
have also been employed with advantage, when indicated by 
constitutional or other general symptoms, but not so frequent- 
ly as those above mentioned. 

Galvanic electricity has relieved a large number of cases, 
and may often be advantageously associated with internal treat- 
ment. According to Benedict, who cured no less than seven- 
teen out of twenty-seven cases by galvanization, the curative 
action takes place, not by the direct excitation of the paralysed 
nerve, but by a reflex irritation through the fifth nerve. The 
same authority states, that in most cases a curative action is 
only observed when the galvanic current is relatively weak. 

Prismatic glasses are sometimes used to neutralize the di- 
plopia, by making the double images to coincide. They may 
also be used therapeutically, by adapting them to the eye in 
such a manner as merely to approximate the images, the para- 
lyzed muscles being benefited by the efforts to unite them. 

If all other means fail, and the affected muscle is not too 
much disabled to be incapable of producing the requisite de- 
gree of contraction, the abnormal direction of the eye may 
sometimes be remedied by tenotomy of the opposing muscle, 
as described under the head of Strabismus, (which see). 



408 PRACTICE OF MEDICINE. 



12-NYSTAGMUS. 

This affection consists in a tremulous or oscillatory move- 
ment of the eye-balls. The oscillations, which are involunta- 
ry and exceedingly rapid, vary in direction, being either hori- 
zontal, oblique, or rotatory. In most cases the movements oc- 
cur simultaneously in both eyes, and in the same direction ; 
but sometimes they take place alternately, and in different di- 
rections. The oscillations are not generally perceptible to the 
patient, nor do they prevent his seeing objects in their true re- 
lations ; but they always impair the sight, rendering the retinal 
images more or less confused, in proportion to the severity and 
extent of the movements. It is also observed that, although 
the eyes appear to act in concert, and the movements take 
place simultaneously, the condition of the sight is often very 
different in the two eyes, and binocular vision is more or less 
disturbed. It is especially difficult for the patient to obtain a 
correct view of small objects, and even large ones, if numerous, 
or in a state of motion, may produce confusion and uncertainty. 
This is remedied to some extent by a habit which the patient 
acquires of involuntarily and unconsciously moving his head in 
a contrary direction to the movements of his eyes, by which he 
is often enabled to keep the visual axes fixed upon the object 
under examination. 

Etiology. — The chief cause of nystagmus appears to be, 
over exertion of the ocular muscles in maintaining the necessa- 
ry convergence of the optic axes for very near vision. This 
over-taxing of the external muscles is generally produced by 
holding objects very near the eyes, in cases of myopia, central 
and other partial cataracts, opacities of the cornea, strabismus, 
functional diseases of the optic nerve and retina, etc. 

Treatment. — As nystagmus usually sets in during in- 
fancy, there is some chance for it to diminish or disappear in 



STRABISMUS. 409 

after life ; but as a general rule it undergoes but little change 
or improvement, even under the most suitable treatment. This 
is due, no doubt, to the fact that a cure can only be effected by 
restoring acuteness of vision to the diseased eyes, and this is 
seldom possible in this class of cases. But good results are 
sometimes obtained by diminishing or neutralizing the impair- 
ment of vision, correcting errors of refraction, and employing 
the eyes in such occupations as will avoid all straining of the 
ocular muscles. We may also derive benefit in some cases 
from the internal use of Agar., Calab., Hyos., Igna., Kali brom., 
Nux v., Puis., and Sant. 

12.-STRABISMUS. 

Although the various forms of squint and their surgical 
treatment have been long known to the profession, yet it has 
been only within a comparatively recent period that our pres- 
ent more accurate knowledge of the pathology of strabismus, 
the result of a careful re-investigation of the whole subject, has 
been obtained. To Prof. Donders, especially, the profession are 
indebted for the first correct view of its nature, and of the inti- 
mate relations which it sustains to the eye as an organ of vision. 
He has clearly shown that, in the beginning, it is in most in- 
stances only a symptom resulting from certain conditions of re- 
fraction ; but that after it has once become established it fre- 
quently proves highly injurious to vision, and may even lead to 
its entire destruction. We are also indebted to his investigations 
for our knowledge of the highly important fact, that one form 
of strabismus frequently depends upon myopia, and the oppo- 
site form upon hypermetropia. 

By the term squint, or strabismus, (strabismus concomitans) 
we understand an inability to direct both visual lines simulta- 
neously upon the same point. If the eye squints inward it is 
called convergent strabismus ; if outward, divergent strabis- 



4IO PRACTICE OF MEDICINE. 

mus; if the deviation is upward, it is called strabismus sursum- 
vergens ; if downwards, strabismus deorsumvergens. If con- 
fined to one eye it is monocular or monolateral; if it alternates 
between the two eyes it is alternating or bilateral. 

Strabismus is also divided into real and apparent, periodic 
and permanent. Apparent strabismus is a form in which, 
though there is a well marked convergent or divergent devia- 
tion of the optic axis, as in real squint, both eyes are neverthe- 
less fixed upon the object, and neither of them undergo the 
slightest movement when the other is closed. Periodic squint 
is occasionally merely a reflex symptom, as in dentition, but 
generally its pathology is the same as that of confirmed stra- 
bismus, of which it is usually but the forerunner. 

A.— Convergent Strabismus. 

As already defined, convergent strabismus is characterized 
by excessive convergence of the visual lines. The conver- 
gence takes place only during binocular vision ; for if the more 
healthy eye is screened, the squinting eye changes its position 
and looks forward. This also proves that the squinting eye is 
but little concerned in ordinary vision. In these cases, if the 
squinting eye is covered, the more healthy one will be found to 
squint. This is called the secondary squint, and is generally 
equal to that of the eye chiefly affected ; but in confirmed stra- 
bismus it is usually more difficult for the squinting eye to di- 
rect its visual line towards a given point than it is for the other. 
In paralytic squint, on the contrary, the secondary deviation is 
the greater. This serves as a ready means of distinguishing 
it from concomitant squint, in which, as we have seen, the pri- 
mary and secondary movements are equal. 

The extent of the squint may be determined with sufficient 
exactness by first marking upon the lower lid the precise situa- 
tion of the pupil or edge of the cornea, when the squinting eye 
is turned strongly inward or outward, and then, having cover- 



CONVERGENT STRABISMUS. 41 1 

ed the healthy eye and fixed the other upon some convenient 
object, measuring the distance between their present and for- 
mer position. 

Convergent squint is generally due to hypermetropia. 
The latter is found to be present in about eighty per cent, of 
the cases of convergent strabismus. The reason it is so often 
overlooked in these cases is, doubtless, because the majority of 
the patients are too young to read. This will also account 
for the fact that periodic squint generally first appears at about 
the fourth or fifth year, or when the child is learning to read 
and spell. The explanation is this : In the hypermetropic 
eye the refractive power is too low, parallel rays reaching the 
retina before being focused, thus creating circles of dispersion 
upon that membrane, and thereby rendering the vision indis- 
tinct. To remedy this defect, the hypermetropic eye is oblig- 
ed to accommodate for distance, just as the normal or emme- 
tropic eye does for near objects. And since near vision re- 
quires a still greater strain of the accommodation, the accom- 
modative faculty, which in hypermetropic eyes is never at rest, 
is soon over-worked. In order to lessen the strain, and at the 
same time increase the power of accommodation, one eye 
squints inward. At first it is periodic, occurring only when 
viewing near objects ; but as the habit becomes confirmed it 
becomes more and more frequent, and finally it takes place at 
all distances, and the strabismus becomes permanent. It is 
not surprising, therefore, that hypermetropia should be a 
frequent cause of convergent squint. The only wonder is that 
it does not occur more frequently amongst hypermetropes than 
it does. Prof. Donders thinks it arises from an effort to avoid 
double vision ; for if one eye of a hypermetrope is screened, it 
will soon turn inward when the other is fixed upon near objects. 
On the other hand, if the degree of hypermetropia is greater 
in one eye than in the other, or if, in consequence of opacity, 
the defect of vision is greater, the tendency to squint is 



412 PRACTICE OF MEDICINE. 

increased, the annoyance from diplopia being no longer 
sufficient to prevent it. In fact, next to hypermetropia, no 
more frequent cause of strabismus is known, than impaired 
vision. It is often seen in cases of opacity of the cornea and 
lens, or in some affection of the deeper structures of the eye in 
which the retinal image is rendered indistinct. In order to 
avoid the confusion resulting from the difference in the visual 
power of the two eyes, the patient involuntarily squints with 
the diseased or more defective eye. The strabismus soon 
becomes confirmed, and finally amblyopia from non-use of the 
eye is added to the defect of vision already existing. It 
should not be forgotten, however, that in many of these cases 
hypermetropia is also present, and may constitute the chief 
cause of the complaint. 

B.— Divergent Strabismus. 

As convergent strabismus is generally associated with 
hypermetropia, so divergent squint is most frequently met 
with in connection with myopia. And as the latter is most 
marked at a later period of life than the former, so divergent 
strabismus generally occurs later, not manifesting itself in 
some cases until after the formation of extensive posterior 
staphyloma. In fact, this is the chief reason that myopes are 
so frequently subject to divergent strabismus. For, as we have 
seen, the elongation of the antero-posterior diameter of the 
globe in myopic eyes, is due in a great measure to the yielding 
of the posterior portion of the globe, which gives it more or 
less of an ellipsoidal shape. In consequence of this extension, 
the mobility of the globe is diminished, and the difficulty of 
rotating it in the orbital cavity is correspondingly increased. 
Now, as myopic vision requires a very great convergence of 
the optic axes, and as this is rendered impossible by reason of 
the ovoidal shape of the globe, it follows that binocular 



TREATMENT OF STRABISMUS. 413 

vision for near objects cannot be maintained without extieme 
exertion. The internal recti muscles soon become fatigued in 
the attempt to maintain the necessary inclination of the optic 
axes, and so to relieve the muscular weariness, and the asthen- 
opic symptoms arising from the strong efforts at accommoda- 
tion, one eye is allowed to diverge, giving rise to one of the 
most common forms of divergent strabismus. But Prof. 
Donders has shown that divergent squint may also be produced 
whenever the degree of myopia becomes so excessive as to 
require too great a convergence of the optic axes for distinct 
vision, or in other words, whenever objects have to be brought 
so close to the eyes that the requisite amount of convergence 
for clear vision cannot be obtained. This is most likely to 
happen if the internal recti muscles are relatively weak. 
Divergent squint is also apt to occur if one eye is amblyopic, 
or more myopic than the other, the diseased eye deviating 
outward, in consequence of the patient relinquishing all effort 
at binocular vision. This form of relative divergence may 
therefore be denominated passive. 

TREATMENT OF STRABISMUS. 

This will differ according as the squint is either paralytic 
or concomitant, convergent or divergent, periodic or permanent. 
If dependent on nervous irritation, the removal of the 
primary disease will be required. Thus, squint arising 
from dentition is best treated by such remedies as Aeon., 
Bell., Cham., Coff., etc. If dependent on verminous affec- 
tions, we should give Cina, Cyclamen, Merc, Sant, Sep., 
Spig., Sulph., etc. Pertussis calls for such remedies as Bell., 
Cast., Cin., Cupr., Dros., Phos., Verat., etc. When produced by 
spasm and convulsions, we may give Agar., Bell., Cic, Cycla., 
Hyos., Stram., Tabac, etc. 

Recent cases depending on hypermetropia or myopia may 
be frequently corrected by using suitable convex or concave 



414 PRACTICE OF MEDICINE. 

glasses, so as to neutralize the errors of refraction. If this is 
not done, the squint will soon become permanent, and then 
tenotomy of the affected muscle will be required. 

As true concomitant squint, when confirmed, can only be 
cured by an operation, the surgeon cannot insist too strongly 
on its early performance, more especially as the neglect to 
perform it has, in thousands of instances, resulted in the loss 
of sight. The operation consists in dividing the tendon of 
the muscle in whose direction the squint occurs, thus permitting 
it to recede slightly, so that it may reattach itself somewhat 
further back. As the pain is severe, nervous persons and 
children will require to be anaesthetized. Then, having separ- 
ated the lids by the stop-speculum, (PL II, Fig. 33), an assistant, 
if the case is one of convergent strabismus, turns the globe 
outwards with a pair of fixing forceps, (Figs. 36, 37); and the 
surgeon, seizing a small fold of the conjunctiva with a pair of 
delicate forceps near the lower margin of the insertion of the 
internal rectus, snips it through with the scissors, being careful 
to make the incision small, so as to obtain, as nearly as possible, 
the advantages of a sub-conjunctival operation. Having 
separated, to a limited extent, the sub-conjunctival tissue from 
the muscle, the surgeon now inserts the strabismus hook 
(PI. I, Fig. 17), beneath the tendon, to hold it and raise it from 
the globe, and it is then carefully divided close to its insertion 
in the sclerotic, unless we desire to increase the effect to be 
produced, when the division may be made farther back ; but, 
on the other hand, if we desire to limit the effect of the 
operation, the edges of the external wound should be brought 
together with a suture. It was formerly the practice in cases 
requiring only a slight degree of correction, say of from one 
to one and a half lines, to sever the tendon only partially, 
leaving a few of the upper or lower fibres undivided ; but this 
is not found to answer the purpose. 

Owing to the great change in the form of the globe, and 



TREATMENT OF STRABISMUS. 415 

the consequent difficulty experienced by the internal recti in 
overcoming the deviation, after section of the external rectus 
for divergent strabismus, it is frequently desirable to keep the 
eye in a position of forced inversion, until the rectus externus 
has acquired a new union with the globe at a point further back 
than would be the case if left to itself. This may be accom- 
plished by passing a suture through the conjunctiva near the 
inner edge of the cornea, and then attaching it to the skin 
near the inner canthus. The suture will cut itself out in the 
course of two or three days, but if the patient is careful not to 
make undue traction upon it, it will not do so until after the 
muscle has formed the requisite attachment. 

The question as to whether we should operate upon one or 
both eyes does not depend upon whether or not both eyes are 
affected with squint, but solely upon its extent. It is found by 
experience that a deviation of from two and a half to three 
lines is all that can be overcome by a single operation ; and 
therefore if the deviation exceeds this amount, we should 
divide it between the two eyes, assigning the greater amount of 
correction to the squinting eye, in order to diminish as far as 
possible the muscular effort. 

After the strabismus has been rectified by division of the 
muscle, if there is any coexisting hypermetropia or myopia, it 
should be immediately neutralized by the proper convex or 
concave glasses, as already explained under the head of anom- 
alies of refraction. This is necessary in order to secure 
binocular vision, to prevent a recurrence of the deformity, and 
to overcome the amblyopia due to the long disuse of the eye. 
The amblyopia is often greatly improved after the operation, 
especially if the sight is exercised with strong and suitable 
glasses. 



416 PRACTICE OF MEDICINE. 

14 -EXOPHTHALMIC BRONCHOCELE. 

MORBUS BASEDOWII, GRAVES' DISEASE, ETC. 

Symptoms. — This disease, the pathology of which is not 
well understood, is characterized by certain functional disturb- 
ances of the circulation, which give rise to violent palpitations 
of the heart, bronchocele, and exophthalmos. The palpitations, 
and other cardiac symptoms, generally occur in paroxysms, 
and are usually accompanied by more or less nervous excite- 
ment and dyspnoea. At first the patient may complain only 
of weariness and exhaustion; but the breathing is almost 
always difficult ; the mucous membranes are pale and anaemic, 
especially the conjunctivae ; digestion is apt to be more or less 
disturbed ; and, if we notice particularly, we may observe a 
peculiar staring expression about the eyes. As the disease 
progresses, the hearts' action becomes strong and tumultuous, 
and is accompanied by loud systolic murmurs ; the paroxysms 
of dyspnoea increase in severity and frequency, during which 
the vessels of the neck frequently beat with great violence ; 
the pulse, which previously was large, full, and perhaps not 
more than 80 or 100 per minute, now ranges from 120 to 150, and 
is irritable and jerking ; the thyroid gland becomes enlarged ; 
the exophthalmos increases, so that the lids no longer cover 
the globes ; the stomach becomes still more disturbed, and the 
debility more marked ; and, as the disease reaches its height, 
the respiration becomes shorter, more accelerated, and frequently 
orthopnceic. Some of these symptoms, however, are not always 
present, especially those connected with derangement of the 
stomach. On the other hand, the digestive troubles may 
become still more pronounced, giving rise to dyspepsia, severe 



EXOPHTHALMIC BRONCHOCELE. 417 

and even bloody vomiting, diarrhoea, hemorrhage from the 
bowels, etc. 

Bronchocele is generally, but not always present in Base- 
dow's disease. An interesting case of this kind has been reported 
by Dr. J. E. Morrison. The patient was a woman, aged 33, of 
nervous temperament, inclined to hysteria; menses "interrupted" 
since the third month after their first appearance. The cata- 
menia usually appeared in the morning and flowed until noon, 
then suddenly ceased, or they would last from half an hour to 
six hours, intermitting in this manner for ten or twelve days. 
During the menstrual period there was active congestion of the 
genital organs, with puffiness of the parts on and around the 
pubis and vulva, exophthalmos, and forcible and tumultuous 
action of the heart, which could be heard several feet from the 
bed. 

The exophthalmos is generally binocular, but does not 
usually become very manifest until some time after the 
appearance of the cardiac symptoms and goitre. Like the 
latter it often varies considerably, especially during the first 
stage, sometimes almost disappearing, at others becoming so 
considerable that the lids cannot be closed. The protrusion of 
the globe, which, as well as the swelling of the thyroid gland, 
has been found to depend upon a dilatation of the vessels, 
particularly of the veins, — generally occurs in an oblique 
direction, and most frequently towards the inner or nasal side. 
In consequence of the long-continued exposure of the cornea 
to atmospheric and other irritating influences, the epithelial 
layers become dry and rough, the xerosis increasing with 
the degree and duration of the exophthalmos. Sometimes, also, 
ulcerations of the cornea occur, which if unchecked may even 
lead to perforation, and, finally, to atrophy of the globe. At 
the same time the lids and conjunctivae become more or less 
swollen and inflamed, and in some cases there are disturbances 
of vision ; but the latter are generally caused by the coexisting 



418 PRACTICE OF MEDICINE. 

xerosis, dilatation of the pupil, etc., and very rarely by real 
amblyopia or amaurosis. 

PATHOLOGY. — As already stated, the exopthalmos is found 
to be due, in the first place, to a hyperaemic swelling of the 
adipose cellular tissue of the orbit, which afterwards becomes 
more or less hypertrophied. This swelling, which may 
generally be diminished by pressure, is said by Virchow to 
rapidly disappear after death. But the true nature of the 
disease, and the relation which the cardiac affection sustains to 
the bronchocele and exopthalmos, are still involved in much 
obscurity and doubt. Some have referred the disease to 
anaemia ; but anaemia, even when it gives rise to palpitations 
and cardiac murmurs, is not generally associated with goitre 
and exophthalmos, nor do these affections produce anaemia. 
Others, again, have attributed the protrusion of the eyes to the 
pressure of the enlarged gland upon the cervical vessels ; but, 
as we have seen, the disease may occur without any enlargement 
of the thyroid, and on the other hand very large bronchoceles 
exist without any exophthalmos. The most rational and 
generally received theory is that which refers the disease to 
functional disturbances of the central parts of the sympathetic 
nerve. Not only do the general symptoms point to disturb- 
ances of the vaso-motor centres, but the almost numberless 
complications of the disease, many of which are of an extremely 
variable and transient character, appear strongly to confirm 
this view of its origin. 

ETIOLOGY. — The disease is generally less severe, occurs at 
an earlier period, and much more frequently, in women than 
in men. It is often associated with disturbances of the uterine 
functions, especially chlorosis, menstrual suppression, etc, or 
with some cutaneous neurosis, such as urticaria. It has also 
been caused by great mental depression, sudden fright, severe 
bodily exercise, hemorrhages, and other debilitating influences. 

Prognosis. — This should always be guarded, especially 



EXOPHTHALMIC BRONCHOCELE. 419 

in the case of males, in whom the symptoms are usually more 
severe and more permanent. The disease is generally slow 
in its progress, especially during the first stage, or before the 
appearance of the goitre and exophthalmos. The symptoms 
frequently abate, or become less frequent ; but relapses often 
occur, and lead sooner or later to faulty nutrition, and in some 
cases to death. Complete recovery is unusual, occurring only 
in about one third of the cases. As a general rule the function 
of the retina remains unimpaired. 

Treatment. — Dr. Morrison's case, above-mentioned, was 
cured by the internal administration of Lycopus virg., a remedy 
which would seem from its provings to be pre-eminently 
adapted to the disorder. Cures, or beneficial results, are also 
said to have followed the use of Amyl nit., Brom., Cact, Fer., 
lod.,* Spong., Nat. m., and Bary. c ; the Amyl nit., being used 
by olfaction alone. Other remedies which deserve attention 
are : — Bell., Calc, China, Cimicif., Dig., Gels., Plat, Puis., Sep., 
Sil., and Sulph. 

Galvanic electricity, applied to the sympathetic nerve, has 
been employed with good success in many cases, especially in 
curing the goitre and exophthalmos, and also in improving the 
general health. This agent is also highly useful in regulating 
the menstrual function, upon the disturbance of which many of 
these cases measurably depend. 

Diet and Regimen. — Experience shows that whatever 
tends to invigorate the general system and improve the health, 
usually exerts a beneficial influence upon the disease. Hence, 
the patient should abstain from the use of stimulants, take 
regular but gentle exercise in the open air, make use of a plain, 
but liberal, nutritious, and easily digestible diet, and, avoiding 
all emotional or other excitement, enjoy as much quiet cheer- 
fulness as circumstances will permit. 



See Am. Horn. 05s., vol. xiii, p. 603. 



420 PRACTICE OF MEDICINE. 



In closing the first volume of our work on the Homoeo- 
pathic Practice of Medicine, we desire to add, that 
notwithstanding it is confined almost exclusively to the 
consideration of diseases of the brain and eye, the affections 
described are amongst the most important that the general 
practitioner is called upon to treat. And if we have appeared 
to give undue prominence to those of the eye, it is because, in 
our opinion, the subjects discussed are too important to be 
dismissed in a few short sections. On the contrary, this 
department of medicine, though somewhat extended, should 
no longer be excluded from our therapeutic treatises. For not 
only are many diseases of the eyes, as we have seen, intimately 
related to those of other parts of the system, but their 
investigation, by throwing new light upon the latter, is full of 
instruction to the general practitioner. Besides, he is frequently 
called upon to treat diseases of the eye under circumstances 
that preclude their being referred to specialists, even if that 
were the proper course to pursue. But as the majority of 
ophthalmic diseases must necessarily be treated by the ordinary 
medical attendant, the propriety of incorporating the requisite 
information in a work of this character, will, we doubt not, be 
generally conceded. 

For reasons which will hereafter appear, we have post- 
poned the consideration of the various organic and functional 
diseases of the brain, until we shall have occasion to take up 
the corresponding affections of the nervous system generally. 



INDEX 



Abnormal astigmatism 

contraction of pupil 

dilatation of pupil 

Abscess of cornea 

globe 

lids 

lachrymal sac 

orbit 

Absolute glaucoma 

Absorption, treatment of cataract 

by 

Accommodation, theory of 

anomalies of 

effect of atropine upon 

paralysis of 

range of 

Acidum nit 130, 135, 143, 

Aconitum 42, 50, 84, m, 117, 

157, 189, 231, 

Acute glaucoma 

Acuteness of vision 372, 403, 

Additional therapeutic indications, 

Agaricus 

Ailantus gland. 

Albugo 

Albuminuria 

Alternation of Medicines 

Alumina 

Amaurosis 256, 

spinal 

Amblyopia 

exanopsia 398, 

Amotio retinae 

Amyl nit 

Anatomy of the eye 

Ankyloblepharon 

Anaemia of the brain 

Anaesthesia retinae 

Aneurism by anastomosis 

Anomalies of refraction 

Apoplexy cerebral 

Anterior chamber of the eye 

Antimonium tart 

Annular staphyloma 

Apis mel Ill, 143, 

Aphakia 

Apthous ophthalmia 

Aqueous humor, hypersecretion of 
181, 

Arcus senilis of the lens 

Argentum nit 

Arnica 43, 79, 189, 

Arsenicum 39, 72, 96, 112, 143, 

157, 189, 220, 



77 



PAGE 

391 
404 
403 
159 
231 
152 
277 
270 
213 

352 

373 
378 
377 
380 

374 
158 

236 
216 

4C5 
281 
281 
281 
116 

257 
18 
281 
400 
401 

393 
412 

3i6 
282 
103 
293 

38 
397 
328 
382 

74 
107 

84 
3H 
231 
37o 
145 

196 

34i 
118 
231 

232 



Arthritic foam 

ophthalmia 

Artificial pupil, operations for 

Asafcetida 

Asarum 

Assalini, on Egyptian ophthalmia. 

Asthenopia 

Arlt.Prof., on catarrhal ophthalmia, 
Astigmatism 

forms of 

treatment of, by lenses 

Atresia pupillae 178, 183, 

Atrophy of the choroid. ..233, 235, 

249, 

eyeball 215, 

retina 249, 257, 

optic nerve 216, 249, 263, 

Atropine, effect of, on the accom- 
modation 

on the iris 

purity of 161- 

Aurum 

Bandage, compress 

in keratitis 161, 

Baryta 79, 

Becker, Dr., on leucaemic retinitis, 

Belladonna, 43, 50, 79, 84, 96, 

ill, 118, 143, 157, 189, 221, 232, 

ointment 

Blear eye 

Blenorrhcea 

of lachrymal sac 

Blepharitis 

ciliaris 

Bowman, Mr., on corneal opacities, 

excision of pupil 

Boynton, Dr., on choroido-retinitis, 

Bronchocele, exophthalmic 

Bryonia 43, 50, 85, 118, 189, 

Buphthaimos 

Cactus grand 157, 

Calabar bean, effect of, on iris 

Calcarea carb 39, 51, 73, 112, 

iod 

Calomel, insufflation of 167, 

Camphora 39, 

Canaliculi, division of 

Cannabis sat 135, 

Cantharis 

Canthoplasty 

Cancer of the eye 

Capsules of Bonnet and Tenon, in- 
flammation of 



PAGE 

212 

210 
190 
282 
282 
123 
388 
122 
391 
392 
393 
190 

253 
230 
263 
400 

377 
186 
note 
282 
172 
172 
282 
258 

236 
187 

150 

120 
278 
149 
150 
3C6 
203 

244 
416 
221 
310 

237 
1 88 

143 
282 
177 
85 
279 
143 
135 
168 

333 
269 



422 



INDEX. 



PAGE 

Capsular cataract 343 

Carcinomatous tumors 333 

Caries of the orbit 274 

Cataract, classification of 337 

adnata 346 

anterior capsular 343 

black 341 

capsular 343 

congenital 337, 346 

cortical 338 

diabetic 346 

glaucomatous 214 

hard 340 

lamellar 337 

mature 339 

mixed 341 

Morgagnian 340, 342 

nuclear 340 

operations for 349 

posterior polar 239, 344 

pyramidal 344 

secondary 340, 342, 345 

senile 340 

siliculose 340 

soft 337 

spectacles for 370 

traumatic 345 

Cataract, treatment of. 347 

by division 352 

by flap extraction 358 

by linear extraction 356 

by peripheral linear extraction 361 

by reclination or couching 354 

by solution 352 

by suction 357 

by Von Graefe's method 361 

Catarrhal ophthalmia...... 109 

Cats-eye, amaurotic 332 

Caustics, on the use of, in episcler- 
itis 174 

in granular ophthalmia 130 

in keratitis 156, 159 

Caustics, on the use of, in purulent 

conjunctivitis 119 

Caustic, special form of J30 

Cedron 221, 283 

Cerebral ancemia 38 

apoplexy 74 

hypercemia 41 

Cellulitis of the orbit 270 

Cephalalgia 49 

Cerebritis 60 

Charpie 172 

Chalazion 321 

Ch amomilla 51, 189 

Chemosis 176 

Chelidonium 283 

China . 40, 51, 97 

Cholesterine in vitreous humor 239 

Choroid 104 

Choroiditis 223 

disseminated or exudative 225 

serous, simple 224 



Choroiditis, syphilitic 225 

suppurative 227 

Chromopsia 229, 396 

Chronic glaucoma 213 

Cicuta 283 

Ciliary body 106 

inflammation of 195 

muscle, paralysis of. 380 

spasm of 381 

neuralgia, 177, 189, 190, 196, 

197, 206, 211 

processes ic6 

Cimicifuga 51, 157, 189, 221 239 

Cina 40 

Cinnabaris 153 

Clematis 153, 283 

Coccius, Prof., ophthalmoscope of.. 365 

Coculus 80 

Coffea cr 43 

Colocynthis 98 

Concussion of the brain 86 

Cohn, Dr., on hypermetropia 390 

on myopia 384 

Colchicum 175, 189 

Collyria 113, 174 

Comocladia 283 

Confirmed glaucoma 211 

Congestion of the brain 41 

Conical cornea 307 

Conium 143, 158, 221 

Conjunctiva. 105 

inflammation of, see Conjunctivitis 

xerosis of 300 

Conjunctival croup..... 136 

discharge, contagiousness of, 

"7, 123 

Conjunctivitis blennorrhoica 114 

catarrhal 109 

exanthematous 147 

diphtheritic 136 

gonorrhceal 132 

granular 126 

neonatorum 114 

phlyctenular 138, 145 

purulent. : 114, 120 

scrofulous 138 

simplex 109 

variolous 148 

Contagious ophthalmia 120 

Contraction of pupil, abnormal 404 

Convergent strabismus 410 

Coredialysis 194 

Corelysis 194 

Cornea 104 

abscess of 159 

conical 307 

herpes of 169 

inflammation of 153 

neuro-paralytic affection of.... 160 

opacities of 1 15, 305 

pannus of 165 

paracentesis of 162 

perforation of 161 



INDEX. 



423 



Cornea, perforating ulcer of 140 

staphyloma of 307 

ulcers of 1 15, 140, 159, 169 

Corneitis, see Keratitis 

Couching 354 

Coup de Soleil 81 

Crocus 237, 284 

Crotalus 284 

Croton tig 284 

Crystalline lens 106 

Cupping of the optic disc, 216, 

234, 235, 401 

Cyclamen 285 

Cyclitis 195 

serous 196 

purulent 197 

Cylindrical lenses 393 

Cyst, tarsal 325 

in iris 325 

in orbit 325 

Cysticercus in the anterior chamber 326 

in the lens 346 

under the retina 326 

Dacryo-adenitis 275 

Dacryocystitis 277 

Definitions and aphorisims 9 

Dermoid tumors 322 

Descemetitis , 181 

Descemet, membrane of 105 

Detachment of the retina 316 

of the vitreous 234, 239 

Digitalis 189 

Dilatation of pupil, abnormal 403 

Diphtheritic conjunctivitis 136 

Diplopia 406 

Direct method of ophthalmoscopic 

examination 367 

Disease, analysis of 22, 23 

causes of 10 

definition of. 9 

suppression of 10 

Dislocation of the lens 346 

Distichiasis 298 

Distoma oculi humani 346 

Divergent strabismus 412 

Division of cataract 352 

Dixon on calcareous deposits in the 

cornea 306 

Dobrowelski, Dr., on protective 

glasses 129, 371 

Donders, Prof., glaucoma of 215 

on hypermetropia 388 

on myopia 238 

on strabismus 409 

Dose, homoeopathic 15 

repitition of 17 

Dropsy of the brain 70 

Drowsiness, morbid 48 

Duct, lachrymal 107 

nasal, stricture of 279 

Double sight 406 

Duration of Medical action 20 

Dyer, Dr., on hypermetropia 391 



PAGE 

Echinococcus, in orbit 325 

Ectropium 296 

Eczema of the lids 149 

Egyptian ophthalmia 123 

Electricity 381, 402, 407, 419 

Electrolysis 329 

Encephalitis 60 

Encephalon, diseases of. 35 

Emmetropia. 382 

Engorged papilla 265 

Entozoa in the lens. 346 

in the orbit 325 

Entropium. 294 

Enucleation of globe 20S 

Epiphora 177 

Episcleritis 1 73 

Epitheliel cancer 334 

Erysipelatous conjunctivitis 147 

Euphorbium m 

Euphrasia in 

Evacuation of the aqueous humor.. 162 

Eversion of the lids 296 

Exanthematous ophthalmia 147 

Excavation of optic nerve, amau- 
rotic 401 

glaucomatous 216, 401 

physiological 216, 401 

Excision of globe 208 

of pupil 203 

Exhaustion, thermic 81 

Exophthalmic goitre 416 

External applications 28 

Extirpation of globe 208 

Extraction of cataract, by flap 

operation 358 

by linear incision 356 

by peripheral linear incision... 361 

by suction 357 

by Van Graefe's method 361 

Eye, enucleation of 102 

diseases of. 208 

general inflammation of. 227 

Eyelashes, inversion of 298 

Eyelids, abscess of 152 

adhesion of 293 

to globe 29T 

erysipelas of 152 

eversion of. ;.. 296 

follicular inflammation of 150 

.inflammation of edges of 150 

Eyelids, inversion of 294 

oedema of 152, 176 

Eye protectors 371 

Face-ache 92 

Far point 373 

Far sightedness 378 

Fatty degeneration of retina, 247, 255 

tumors 327 

Fibroma of eyelid , 329 

of orbit 330 

Field of vision, state of in amauro- 
sis 402 

in choroiditis 225 



424 



INDEX. 



PAGE 

Field of vision, in detachment of 

retina 317 

illustrations of 244, 245 

in glaucoma 214 

in hyalitis 239 

in retinitis, 243, 248, 253, 256, 

260, 262 

Filaria oculi humani 346 

Fistula of lachrymal gland 275 

ofthe sac 278 

Flap extraction of cataract 358 

Fluoric acid 285 

Fomentations in suppurative kera- 
titis 162 

Foreign bodies in the eye 206 

Functional diseases of the eye 373 

Fundus oculi, ophthalmoscopic ap- 
pearances of 367 

Fungus heematodes of eyeball 332 

Galazowski,Dr., on vitreous humor, 238 

Gelseminum 43, 98, 158, 222 

in choroido-retinitis 244 

General observations Q 

Giddiness 47 

Gland, lachrymal 107 

inflammation of 275 

Glaucoma 209 

acute inflammatory 210 

chronic inflammatory.. 213 

non inflammatory 215 

fulminans 213 

hemorrhagic form 218 

iridectomy in 219 

myotomy in 219 

nature of. 217 

ophthalmoscopic symptoms of, 216 

paracentesis in 219 

premonitory stage of 210 

prognosis of. 218 

sclerotomy in 219 

secondary 234 

simplex 215 

subacute 213 

treatment of 219 

Glioma retinae 33 1 

Glonoine 51, 64, 85 

Goitre, exophthalmic 416 

Gonorrhceal ophthalmia 132 

Graefe, Von, Prof., on bandages for 

the eye 162 

on ephemeral mydriasis 404 

on fomentations 157 

on hypopya 183 

on irido-choroiditis 202 

on operation for cataract 361 

on optic neuritis 266 

on transitory amaurosis 395 

on trichiasis 299 

on sclero-choroiditis posterior, 235 
on structure of vitreous hu- 
mor 224 

on sympathetic ophthalmia 206 

Granulations, chronic 129 



Granulations, diaphanous 109 

Granular ophthalmia 126 

Graphites 130, 144 

Graves' disease 416 

Gummy tubercles of the iris 184 

Hamamelis 222, 285 

Hahnemann's law of cure II 

Headache 49 

Helleborus 73, 85 

Hemorrhage after enucleation 209 

Helmholtz, Prof., on acccommoda- 

tion ofthe eye 376 

his invention of ophthalmo- 
scope 365 

Hemeralopia 398 

Hemiopia 285, 289 

Hepar sulph c, 98, in, 118, 135, 

H4, 158, 232 

Herpes of the conjunctiva 145 

ofthe cornea 169 

Herpetic bridge 170 

Heymann, on retinitis apoplectica, 260 
Hirschberg, Dr., ou glioma retinae 332 

Homoeopathic aggravation 14 

dose 15 

materia medica 14 

regimen 29 

Hordeolum 319 

Horns 323 

Hyalitis 237 

simple 238 

suppurative 240 

Hydatids of orbit 325 

Hydrastis can 112 

Hydrocephalus, acute 65 

chronic 70 

Hydrophthalmia, anterior 217 

Hypersemia of the brain 41 

Hyoscyamus 85 

Hypersesthesia of retina 396 

Hypermetropia..., 388 

diagnosis of 389 

frequent cause of asthenopia... 388 

of convergent squint 390, 411 

varieties of 388, 389 

Hypopyon 159, 182, 228 

posterior 240 

Ignatia 52 

Illumination, lateral 368 

Indirect method of ophthalmosco- 
pic examinations 366 

Infinite distance, what is meant by 373 
Inflammation of orbital cellular 

tissue. 270 

of the brain and its mem- 
branes 56 

of the substance of the brain.. 60 
Inflammation of capsule of Tenon.. 269 

of choroid 223 

of ciliary body 195 

of conjunctiva 108 

of cornea 153 

of eyelids 150 



itfDEX. 



42S 



Inflammation of eyelids, edge of.... 150 

of eye generally 227 

of iris 175 

of iris and choroid 198 

of lachrymal gland 275 

of lachrymal sac 277 

of retina 241 

of sclera 172 

sympathetic 204 

of vitreous humor 237 

Insomnia 48 

Induration of the brain 61 

Insufflation 167 

Interstitial keratitis 153 

Intra-ocular tension, increase of, 

in glaucoma 213 

Inversion of lid 294 

Iodium 65, 112, 130 

Ipecacuanha 40, 52 

Iridectomy 190 

in glaucoma 192, 219 

in irido-choroiditis 202 



in iritis , 

in keratitis 157, 

when indicated , 

Iridenkleisis , 

Irido-choroiditis, simple 

glaucomatous 

pseudo-membranous , 

Irido-cyclitis 

Iiidodesis 

Iridodialysis 

Iridotomy 

Iris 



color of 

inflammation ot 

prolapse of 1 16, 

versicolor 

Iritis 

parenchymatous 

serous 

simple 

suppurative 

syphilitic 

traumatic 

Ischaemia of the disc 

Iwanoff on detachment of the vitre- 
ous 234, 

Jackson, Dr., on optic-neuritis 

Jaeger, Prof., on posterior staphy- 
loma 

test-types of 

Kali iod 131, 158, 189, 

bich 

Kalmia 99, 

Keratitis, diffuse 

pannosa 

punctata 181, 

phlyctenular 

suppurative 

syphilitic 

vascular 

Kerato-conus 



192 

163 
192 

193 
198 
209 
200 
196 

193 

194 
194 

105 
179 

175 
140 

99 

175 
182 
181 

175 
182 



179 
265 

239 

267 

235 

372 
222 

285 
285 

153 
165 

224 
169 
159 
155 
165 
308 



Kerato-iritis 155, 177 

Kerato-globus 310 

Keratonyxis 353 

Lachesis 80 

Lachrymal apparatus 107 

fistula of. 275, 278 

inflammation of 275 

Lagophthalmos 300 

Lateral illumination 368 

Laurocerasus 80 

Leber, Dr., on leucsemic retinitis.. 258 
Lens, crystalline , 106 

dislocation of 224, 346 

Lenses 278 

instrument for ascertaining the 

focal strength of. 279 

Leucoma 116 

Liebreich, Dr., ophthalmascope of 365 

on leucsemic retinitis 258 

Lippitudo 150 

Linear extraction in cataract 356 

peripheral 361 

Long-sightedness 388 

Lycopodium 131 

Lycopus. 286 

Macula lutea 106 

ophthalmoscopic appearance of 367 
Mackenzie, Dr., on post-febrile 

ophthalmia 203 

Manz, Dr., on optic-neuritis 265 

Materia Medica, homoeopathic, 14 

defects of 103 

Measles, ophthalmia of 148 

Medical nomenclature S3 

Medullar)' cancer 335 

Meningitis 56 

granular 56 

tuberculous 65 

Meissner, on neuroparalytic oph- 
thalmia 160 

Mercurius 44, 52, 73, 80, 

99, I", 131, »35» r 44, 158, 

189, 232, 280 

corrosivus 237 

proto-iodatus 175 

Mezereum 99 

Micropsia., 249-note 

Military ophthalmia 120 

Milium 326 

Moluscum 326 

Monostoma lentis 346 

Morbus Basedowii 416 

Mucous ophthalmia 109 

Muriate of hydrastia 118 

Muscles of the eye, paralysis of... 405 

spasm of 408 

Mydriasis 403 

Myopia 383 

frequent cause of divergent 

squint 412 

Myosis 404 

Myotomy in glaucoma 219 

Nsevus maternus.. 327 



426 



INDEX. 



PAGB 

Nasal duct, treatment of stricture 

of 279 

Near point 374 

Near-sightedness 383 

Nebulae of cornea : 154 

Necrosis of orbit 274 

Neonatorum, ophthalmia 1 14 

Neuralgia trigemini 92 

Nephritic retinitis 254 

Neuritis, optic, ascending 265 

descending 266 

Nighr-blindness 398 

Nomenclature medical 33 

Nux vomica 40, 44, 52, 80, 99 

Nyctalopia 396 

Nystagmus 408 

Oblique illumination 368 

CEdema of conjunctiva 121, 132 

of eyelids 152 

of retina 242 

Ointment, belladonna 187 

Onyx 159 

Opacities of cornea 305 

of lens 337 

of vitreous 234, 238, 315 

Ophthalmia, arthritic 2IO 

catarrhal . 109 

diphtheritic 136 

Egyptian 123 

exanthematous 147 

gonorrhoeal 132 

granular 126 

military 120 

neanatorum 114 

neuro-paralytic 160 

phlyctenular 138, 145 

post-febrile 203 

purulent 1 14, 120 

rheumatic 180 

scrofulous 138 

sympathetic 204 

tarsi .♦. 150 

venous 210 

Ophthalmic symptoms, table of..... 288 

Ophthalmoscope 364 

direct method of examination 

by 367 

indirect method 366 

various forms of... 365 

Ophthalmoscopic appearances of 

the fundus oculi 367 

of the optic papilla, normal.... 216 

Opium 44, 80 

Optic nerve 106 

Optic Nerve, atrophy of...257, 263 267 
cupping or excavation of, 216, 

234, 235, 401 
disc, normal appearance of..... 216 

dropsy of 265 

inflammation of. 264 

neuritis 264 

ascending 264 

descending 266 



PAGB 

Optical aids and tests... 364 

Ora serrata 106 

Orbit, abscess of 269 

caries of. 274 

cellulitis of 270 

hydatids in 325 

' necrosis of 274 

periostitis of. 273. 

tumors, cystic 325 

fatty 327 

fibrous 330 

sarcomatous 331 

vascular 326 

cancer of 334 

epithelial 334 

medullary 335 

melanotic 336 

Oscillation of eyeballs..... 408 

Pagenstecher, Dr., on vitreous hu- 
mor 237 

Pannus 128, 165 

Panophthalmitis 227 

Pantoscopic spectacles 369 

Paracentesis cornese 162; 188 

Paralysis of ciliary muscle 380 

of ocular muscles 405 

Parenchymatous keratitis 153 

Passavant, Dr., on corelysis 195 

Perforation of cornea 161 

Periostitis of orbit 273 

Peripheral linear extraction of 

cataract 361 

Periscopic spectacles 370 

Petroleum 253 

Phlegmonous inflammation of eye- 
lids 152 

Phlyctenular ophthalmia 138, 145 

Phosphenes 304 

Phosphorus 112, 222, 237 

Photophobia 177 

scrofulosa 139 

Photopsia 229 

Physostigma ven 237 

Phytolacca 222, 286 

Pigment degeneration of retina 261 

Platina....!. 100 

Polypi, conjunctival 327 

Plumbum 65, 73 

Posterior chamber 107 

Post-febrile ophthalmia 203 

Posterior polar cataract 239, 344 

Preliminary observations on the 

eye 102 

Presbyopia 378 

Pressure bandage 172 

Prisms 407 

Prismatic spectacles 407 

Prolapse of iris 116, 140 

Prosopalgia 92 

Prosopon, diseases of the 92 

Protrusion of globe 270, 331, 

333, 4i6 
Prunus sp 286 



INDEX. 



427 



PAGE 

Psora 10 

Psorinum » 224 

Psorophlhalmia 149 

Pterygium 301 

operations for 303 

Ptosis 405 

Pulsation of retinal vessels 217 

Pulsatilla 44, 52, 8t, 144 

Puncta lachrymalia, eversion of... 150 

Punctum proximum 374 

remotissimum 373 

Pupil, artificial, operations for 190 

adhesions of 178 

contraction of. 178, 404 

dilatation of 181, 186, 403 

exclusion of. 199 

occlusion of 200 

Purulent cyclitis 197 

ophthalmia 114, 120 

of adults 120 

of infants 114 

chronic 126 

Pustular ophthalmia 143 

Range of accommodation 374 

Reclination of cataract 355 

Recklinghausen, on leucsemic re- 
tinitis 258 

Refraction, anomalies of 382 

Regimen, homoeopathic 29 

Results of ophthalmic inflammation 291 

Reichert, membrane of 105 

Retina 106 

anaesthesia of. 397 

atrophy of. 243, 249 

detachment of 239, 316 

fatty degeneration of ..247, 255 

glioma of 331 

hyperassthesia of 241, 396 

inflammation of 241 

cedema of 242 

operation in detachment of.... 319 

pigment degeneration of 261 

sclerosis of 247, 256 

Retinitis 241 

albuminunca 254 

apoplectic 259 

exudative 247 

leucsemic 258 

Retinitis, nephritic 254 

parenchymatous 247 

pigmentosa 261 

serous 242 

syphilitic 251 

traumatic 244 

Rheumatic iritis 179 

Rhododendron 222 

Rhus tox...45, 100, 113, 118, 144, 232 

Ruta 286 

Sac, lachrymal, inflammation of.... 277 

fistula of 278 

Saemische, Dr., operation for ulcus 

serpens cornese 163 

Sanguinaria 53 



PAGB 

Santonine 287 

Sarcoma 331 

Scarlatina, ophthalmia of 148 

Schlemm, canal of 105 

Scirrhus 336 

Sclerectasia posterior 233 

Sclera, sclerotica.., 104 

inflammation of 172 

Sclerotomy in glaucoma 219 

Sclero-choroiditis posterior 233 

Scotomata 225 

Scrofulous ophthalmia 138 

inflam. ofbrain 66 

. Sebaceous cysts 323 

Secale cor 41 

Secondary cataract 340 

Selection of remedies ^ 24 

Senega 287 

Sepia 53, 100 

.Shields, glass, in symblepharon 292 

Short-sightedness 383 

Silicea 73, 85, 144 

Similia Similibus £urantur II 

Sleeplessness 48 

Small-pox, ophthalmia in 148 

Snellen, Dr., test-types of 372 

Snow-blindness 397 

Softening oi the brain 60 

Solio ictus 81 

Solution of cataract 352 

Spasm of ciliary muscle 381 

Spectacles 369, 370, 371 

Spier's lachrymal catheter 280 

Spigelia 100, 158, 190, 222, 237 

Squint see Strabismus 

Staphyloma 307 

of cornea and iris 311 

operations for 313 

annular 314 

anterior 173, 314 

posterior 233 

racemosum 133 

treatment of 309, 312 

Staphysagria 112, 144, 287 

Steilwag, on curability of cataract, 347 

on post-febrile ophthalmia 204 

on syphilitic retinitis 251, 252 

Stenapaic spectacles 370 

Sticta 287 

Strabismus 409 

apparent 410 

Sti-abismus, concomitans 409 

convergent 410 

divergent 412 

monolateral 410 

passive 413 

periodic 410, 41 1 

treatment of.., 413 

Stramonium 53> 81 

Stupor 48 

Stye 319 

Substitution of medicines 25 

Suction operation for cataract. .... 357 



428 



INDEX. 



Sulphur 53, 73, 112, 131, 144, 

Sunstroke 

Suppurative cyclitis 

iritis 

keratitis 

Symblepharon 

operations for 292, 

Sympathetic ophthalmia 

Symptomatology 

Symptoms 

totality of 

Synchysis 

Synechia, ann ular 178, 

anterior 

posterior 180, 

Syphilitic iritis 

keratitis 

retinitis 

Syringe, suction, for cataract 

Table I. Analysis of Disease, 22, 

II. Substitution 

III. Cerebral regions 

IV. Cerebral sensations.... 

V. Cerebral congestion 

VI. Cephalalgia, its causes, 
&c 

VII. Cephalalgia, its seat 
and character 

VIII. Meningitis 

IX. Acute hyrocephalus — 
symptoms 68, 

XI. Concussion — synopsis 
of treatment 

XII. Cerebral diseases 

XIII. Prosopalgia 

XIV. A. Ophthalmic symp- 
toms 

XV. B. Ophthalmic Inflam- 
mation 

Table A. — Ophthalmic symptoms.. 
B. — Ophthalmic inflammation 

Tarsal cysts 

ophthalmia 

Tarsoraphia 

Teale, Mr., on suction operation 

for cataract 

Telangiectasis 

Tenon, inflammation of capsule of, 

Tenotomy for strabismus 

Tension, intra-ocular, in glaucoma, 

Test-types 

Therapeutic indications, 39, 42, 50, 

72, 79, 84, 92, m, 118, 

i35» '43, J 57. 189, 22o f 

236, 

Thuja 112, 118, 



223 
81 

197 

182 

159 
291 

293 
205 

12 
9 

13 
239 
198 
116 
194 
184 
155 
251 
357 

23 

27 

.36 

37 
46 

54 

55 
58 

69 



90 
101 

288 

290 
288 
290 
321 
149 
297 

357 
327 
269 
414 
213 
37i 

231, 
281 

131 



Tic douleureux , 92 

Tobacco amaurosis 401 

Tracoma 126 

ficosa 129 

Traumatic cataract 345 

Trichiasis 298 

Tumors, ophthalmic 319 

dermoid 322 

carcinomatous 333 

cystic 324 

fatty 326 

fibrous 329 

sarcomatous 330 

sebaceous 323 

Ulcer, resorption 169 

of the brain 61 

of cornea 140, 159, 169 

Uveal tract 196 

Variolous ophthalmia 148 

Venous circle 211 

ophthalmia 210 

pulsation of central vessels... 217 

Veratrum album 41 

(( viride 45, 85 

Verbascum 100 

Vertigo 47 

Vesicular tumors 325 

Virchow, Prof., on Bright's disease 257 

on dermoid tumors 323 

on glioma retinae.. 332 

on vitreous humor 238 

Vitreous humor..... 107 

chloresterine crystals in 239 

detachment of 234, 239 



fluid 



idition of. 



239 



inflammation of 237 

opacities of 238,240, 315 

Walton, Mr. Haynes, on symble- 
pharon 292 

Warts 323 

Weakness of sight 388 

Weber, Dr.. canaliculus knife of... 279 

on vitreous humor 238 

Wecker, De, Dr., on hypermetro 



pia. 



390 



137 
260 



Wells, Dr 157, 161, 174, 

Williams, Dr 

207, 251, 
Wordsworth's glass shields in sym- 
blepharon 292 

Xerophthalmia 300 

Zehender, Prof., ophthalmoscope of 365 

Zinc 73, 81 

Zinc, chloride of, paste 336 

phos 237, 287 

Zonule of Zinn 106 



X 2345^789 *o n la i3 14 xs 16 17 




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